A client presents to the emergency department complaining of headaches and blurred vision. The client's vital signs are as follows, Pulse 102 beats/minute, BP 172/92. RR 20 breaths/minute, SpO2.97% on room air temperature of 98.64. Which of the following interventions would be most appropriate for this patient?

Administer IV hydralazine and monitor blood pressure

Administer oxygen at 10 liters/minute by non rebreather mask

Administer acetaminophen 650 mg PO re-check temperature

Infuse 0.9% sodium chioride at 120 mL/hour

Answer and Explanation

The Correct Answer is A

A) "Administer IV hydralazine and monitor blood pressure":
. The patient's elevated blood pressure (172/92 mmHg), along with headaches and blurred vision, could indicate a hypertensive emergency, a serious condition where extremely high blood pressure can cause acute organ damage. Hydralazine is a common intravenous antihypertensive medication used to lower blood pressure quickly in these situations. The nurse should administer hydralazine as prescribed and closely monitor the blood pressure to prevent complications like stroke, heart failure, or kidney damage. Blood pressure management is the priority, as the patient's symptoms are likely related to the elevated BP.

B) "Administer oxygen at 10 liters/minute by non-rebreather mask":
. While oxygen therapy may be appropriate for patients with respiratory distress or hypoxia, the patient's SpO2 is 97% on room air, indicating that there is no immediate oxygenation issue. Administering oxygen unnecessarily could lead to oxygen toxicity, and it is not the priority in this case. The patient's main concern is their elevated blood pressure, which requires urgent management.

C) "Administer acetaminophen 650 mg PO re-check temperature":
. While headaches are one of the patient's complaints, there is no indication of fever (the temperature is 98.6°F). Administering acetaminophen would be appropriate for pain relief, but it is not the priority in this case. The elevated blood pressure and potential hypertensive emergency are the primary issues that need to be addressed first.

D) "Infuse 0.9% sodium chloride at 120 mL/hour":
. Normal saline (0.9% sodium chloride) is typically used for hydration, but there is no indication that the patient is dehydrated or that intravenous fluids are the priority. In cases of hypertensive emergency, the goal is to lower blood pressure using antihypertensive medications, not to infuse fluids. Fluid administration could potentially worsen the situation if the elevated blood pressure is not addressed first.

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Correct Answer is C

Explanation

A. Recent thoracic surgery within the past week:
Recent surgery, especially in the thoracic region, is a contraindication for the use of tissue plasminogen activator (tPA) in stroke treatment. tPA is a thrombolytic agent that dissolves clots, but it also increases the risk of bleeding, including in areas where surgery has recently occurred. Using tPA in this situation can potentially lead to life-threatening bleeding complications.

B. Uncontrolled hypertensive crisis:
Uncontrolled hypertension is a contraindication for tPA. High blood pressure can increase the risk of hemorrhagic transformation (bleeding into the brain) when using thrombolytic therapy like tPA. A hypertensive crisis (typically systolic BP > 185 mmHg or diastolic BP > 110 mmHg) must be managed and brought under control before administering tPA to minimize the risk of bleeding complications.

C. Age over 65 years:
While age over 65 years may increase the risk of complications from tPA, it is not an absolute contraindication for its use. Guidelines for tPA administration in stroke patients typically focus more on factors like time from symptom onset (usually within 4.5 hours), the presence of contraindications like recent surgery or uncontrolled hypertension, and the overall clinical condition. Age itself is not a reason to withhold tPA unless other risk factors are present.

D. Head trauma with active cerebral hemorrhage:
Head trauma with active cerebral hemorrhage is a definitive contraindication for tPA. Since tPA is a clot-busting drug, it can worsen bleeding in the brain, especially in cases where there is ongoing hemorrhage from trauma. This significantly increases the risk of severe neurological damage and even death, so tPA should not be administered in such situations.

A. NG tube placement B. Low calorie and low protein diet C. Stool softeners and laxatives D. Barium contrast imaging studies

Correct Answer is A

Explanation

A. NG tube placement:
In patients with an exacerbation of inflammatory bowel disease (IBD), particularly in cases of severe flare-ups, the gastrointestinal tract may need rest, and the patient may have difficulty maintaining adequate nutrition. An NG (nasogastric) tube may be used for enteral feeding if the patient is unable to tolerate oral intake, or to provide bowel rest if indicated. Nutritional support via an NG tube can help provide essential nutrients and manage symptoms during an exacerbation, especially if the patient is experiencing severe nausea, vomiting, or malabsorption.

B. Low calorie and low protein diet:
During an IBD flare, the patient typically needs a higher-calorie, higher-protein diet to support healing and immune function. A low-calorie, low-protein diet would not be appropriate, as it would not provide the necessary nutrients for recovery and tissue repair. In fact, nutritional support is often one of the key components in managing IBD exacerbations. A diet rich in calories and protein is often recommended to prevent malnutrition.

C. Stool softeners and laxatives:
Stool softeners and laxatives are generally contraindicated during an IBD flare, as they can exacerbate diarrhea and increase bowel motility, which may worsen symptoms such as abdominal pain, cramping, and diarrhea. The focus during an exacerbation of IBD is typically on controlling inflammation, rest, and reducing bowel irritation, rather than promoting bowel movements.

D. Barium contrast imaging studies:
Barium contrast imaging studies are generally not performed during an acute exacerbation of IBD because they can cause further irritation to the inflamed bowel. Imaging studies are typically used for diagnosis and assessment of disease extent in a stable or chronic phase, rather than during an acute flare. The priority during a flare is managing symptoms and controlling inflammation, not conducting procedures that could aggravate the condition.

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Naxlex Comprehensive Predictor Exams

Which of the following is not a contraindication for the use of tissue plasminogen activator (PA) in the treatment of stroke?

Correct Answer is C

Explanation

The nurse is caring for a client with an exacerbation of inflammatory bowel disease: Which of the following orders would be anticipated for this patient?

Correct Answer is A

Explanation

The nurse knows that all of the following are features of ulcerative colitis except?

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