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.
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Related Questions
Correct Answer is B
Explanation
A. Assessing for upper extremity injuries is important, but it is not the highest priority in an unconscious client who is at risk for airway obstruction.
B. Suctioning saliva from the client's mouth is the highest priority because an unconscious client is at risk for airway obstruction due to the accumulation of saliva or other secretions. Maintaining a clear airway is essential to prevent aspiration and ensure adequate oxygenation.
C. Monitoring electrolyte levels is important in the overall management of a client with cerebral hemorrhage, but it is not the immediate priority compared to securing the airway.
D. Recording intake and output is necessary for fluid balance monitoring but is secondary to the immediate need to maintain a patent airway in an unconscious client.
Correct Answer is A
Explanation
A. Insulin lispro is a rapid-acting insulin that should be administered 15-30 minutes before a meal to manage blood glucose levels effectively. This timing helps to match the peak action of the insulin with the rise in blood glucose levels after eating.
B. Hypoglycemia from insulin lispro typically occurs within 1-3 hours of administration, not 4 hours later. Regular monitoring during this time frame is more appropriate.
C. An increase in appetite is not a direct result of insulin lispro administration and does not indicate insulin effectiveness or safety.
D. Insulin lispro and insulin glargine should not be mixed in the same syringe as they have different action profiles and pH levels, which can affect their efficacy.
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