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 A
Explanation
A. Petechiae are small, red or purple spots on the skin that indicate bleeding under the skin and are a classic sign of thrombocytopenia, a condition characterized by a low platelet count.
B. A decreased white blood cell count is more indicative of leukopenia, not thrombocytopenia. Thrombocytopenia specifically affects platelet counts.
C. Increased fatigue can be a symptom of many conditions but is not specific to thrombocytopenia. It may occur due to anemia or other side effects of chemotherapy.
D. Unexplained bone pain is not a typical symptom of thrombocytopenia. It might be related to other conditions or side effects but is not specific to low platelet counts.
Correct Answer is C
Explanation
A. An HbA1c level of 7.5% indicates suboptimal long-term glucose control. The target for many diabetic patients is usually below 7%, but it may not require immediate action compared to more acute indicators.
B. A 2-hour post-prandial blood glucose level of 122 mg/dL is slightly above the normal range but not significantly high. This result alone is not as indicative of inadequate control as other values.
C. A random blood glucose level of 300 mg/dL is significantly elevated and indicates poor glucose control. This value is much higher than the normal range and suggests a need for further teaching and adjustment of diabetes management.
D. A fasting blood glucose level of 48 mg/dL is low and could indicate hypoglycemia rather than inadequate control. This level requires immediate attention but does not reflect poor long-term diabetes management.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.