A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?
Current anticoagulant use
Blood pressure of 160/85 mm Hg
Complete neurologic assessment
Current treatment for client's peptic ulcer disease
The Correct Answer is A
A. Current anticoagulant use is crucial to assess before administering t-PA because combining t-PA with anticoagulants can significantly increase the risk of bleeding complications. It is essential to ensure that the client is not on medications that could interact adversely with t-PA.
B. While blood pressure is important to monitor, it is secondary to assessing anticoagulant use since high blood pressure alone does not contraindicate t-PA administration.
C. A complete neurologic assessment is important for determining the extent of the stroke but is not the immediate priority before administering t-PA.
D. While treatment for peptic ulcer disease is relevant, it is not directly related to the immediate risk factors for t-PA administration compared to anticoagulant use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["11.074"]
Explanation
To calculate the infusion rate, we'll use the following formula:
Infusion rate (mL/hr) = Desired dose (units/hr) / Concentration of heparin (units/mL)
First, calculate the desired dose in units/hr:
- 14 units/kg/hr x 79.1 kg = 1107.4 units/hr
Next, calculate the concentration of heparin in the IV bag:
- 25,000 units / 250 mL = 100 units/mL
Finally, plug the values into the formula:
- Infusion rate = 1107.4 units/hr / 100 units/mL = 11.074 mL/hr
Correct Answer is ["B","C","D","E"]
Explanation
A. Osteoarthritis is not associated with hearing loss
B. The client's place of employment as a firearms instructor at a shooting range exposes them to loud noises, which is a well-known risk factor for hearing loss.
C. Gentamycin is an aminoglycoside antibiotic that can be ototoxic, especially when administered in high doses or for prolonged periods, potentially leading to hearing loss.
D. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that has been associated with an increased risk of hearing loss, particularly when taken regularly or in high doses.
E. Bumetanide is a loop diuretic that can also have ototoxic effects, especially when used in conjunction with aminoglycoside antibiotics like gentamycin.
F. Heart failure is not associated with hearing loss
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