A client in the emergency department is being prepared to receive tissue plasminogen activator (tPA). The nurse knows that which of the following is true regarding this medication?

The medication should be given with 5-6 hours of the onset of stroke systems

The medication is a primary treatment for haemorrhagic stroke.

The medication can be given to prevent clot formation in the context of head trauma

When given within a certain timeframe, the medication may dissolve an ischemic stroke

Answer and Explanation

The Correct Answer is D

A) "The medication should be given with 5-6 hours of the onset of stroke symptoms":
. tPA (tissue plasminogen activator) is typically given for an ischemic stroke, and it is most effective when administered within 3 to 4.5 hours of the onset of stroke symptoms. After this time frame, the risk of bleeding complications increases, and the benefits of the medication diminish significantly. Giving tPA after 6 hours is generally considered outside the therapeutic window for ischemic stroke, though some centers may extend the window based on specific criteria.

B) "The medication is a primary treatment for hemorrhagic stroke":
. tPA is contraindicated in hemorrhagic stroke because it works by dissolving clots, which could worsen bleeding in the brain. Hemorrhagic stroke occurs when there is bleeding in the brain, and administering tPA would exacerbate the bleeding, leading to more severe brain injury and complications. The primary treatment for hemorrhagic stroke is controlling bleeding, often through surgical interventions or managing blood pressure.

C) "The medication can be given to prevent clot formation in the context of head trauma":
. tPA is not used to prevent clot formation, particularly in the setting of head trauma. It is used to dissolve existing clots in cases of ischemic stroke. Administering tPA after head trauma or brain injury could lead to catastrophic complications, such as worsening bleeding, and should be avoided. The use of tPA is contraindicated in trauma-related situations unless the stroke is clearly ischemic and there are no signs of hemorrhage.

D) "When given within a certain timeframe, the medication may dissolve an ischemic stroke":
. tPA is the standard treatment for ischemic strokes (caused by a clot blocking blood flow to the brain). When administered within 3 to 4.5 hours of the onset of symptoms, tPA can dissolve the clot, improving blood flow to the affected area of the brain and potentially minimizing the damage caused by the stroke. Timely administration is critical for maximizing its benefits in reducing disability and improving outcomes.

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Correct Answer is ["44"]

Explanation

Total volume to infuse: 400 mL

Infusion time: 3 hours

Drop factor of tubing: 20 gtt/mL

To find:

Drip rate (gtt/min)

Step 1: Convert infusion time to minutes

3 hours x 60 minutes/hour = 180 minutes

Step 2: Calculate the total number of drops

Total drops = Total volume x Drop factor

Total drops = 400 mL x 20 gtt/mL = 8000 gtt

Step 3: Calculate the drip rate

Drip rate = Total drops / Infusion time in minutes

Drip rate = 8000 gtt / 180 minutes = 44.44 gtt/min

Step 4: Round to the nearest whole number

44 gtt/min

A. RBCs 4.3mEq/L B. Potassium 4.8 mEq/L C. Hemoglobin of 9g/dl D. Sodium 137 mEq/L

Correct Answer is C

Explanation

A) RBCs 4.3 million/µL:
While a low RBC count can indicate anemia, the specific value provided here is not suggestive of anemia, and it does not explain the patient's symptoms of fatigue, weakness, and dizziness as clearly as a low hemoglobin would.

B) Potassium 4.8 mEq/L:
This result is not concerning and does not directly relate to the patient's reported symptoms of pallor, fatigue, and dizziness. Therefore, this lab result does not take priority in planning care at this time.

C) Hemoglobin of 9 g/dl:
This result is consistent with anemia, which is a likely cause of the patient’s symptoms of fatigue, weakness, dizziness, and pallor. Anemia can lead to decreased oxygen delivery to tissues, explaining the symptoms the patient is experiencing. The priority action for the nurse should be to address the underlying cause of anemia and manage it to improve the patient’s oxygenation and overall condition.

D) Sodium 137 mEq/L:
Although sodium imbalances can cause neurological symptoms such as confusion or lethargy, the patient’s reported symptoms of pallor, fatigue, and dizziness are more likely related to anemia. Sodium is not the most urgent concern for this patient at the moment.

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A client in the emergency department is being prepared to receive tissue plasminogen activator (tPA). The nurse knows that which of the following is true regarding this medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["44"]

Explanation

The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse’s priority for planning care?

Correct Answer is C

Explanation

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