A nurse in an emergency department is caring for a client who has manifestations of an ischemic stroke that began 2 hr ago. Which of the following actions should the nurse take?
Initiate fibrinolytic therapy.
Place the client in a supine position.
Prepare the client for a chest x-ray.
Insert an indwelling urinary catheter.
The Correct Answer is A
Rationale:
A. Initiate fibrinolytic therapy: Fibrinolytic therapy, such as tissue plasminogen activator (tPA), is most effective when administered within a 3- to 4.5-hour window from the onset of ischemic stroke symptoms. Early administration can dissolve the clot, restore cerebral blood flow, and improve neurological outcomes.
B. Place the client in a supine position: Clients with ischemic stroke are usually positioned with the head of the bed elevated 15–30 degrees unless contraindicated. Supine positioning can increase intracranial pressure and risk aspiration, which may worsen neurological status.
C. Prepare the client for a chest x-ray: A chest x-ray is not a priority in acute ischemic stroke management. Immediate neuroimaging, typically a CT scan, is required to differentiate ischemic from hemorrhagic stroke before initiating fibrinolytic therapy.
D. Insert an indwelling urinary catheter: Inserting a catheter is not indicated as an initial intervention for acute stroke unless the client is unable to void or requires strict output monitoring. Priority actions focus on neuroprotection and reperfusion therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A single light fixture hangs along the sidewalk to the house: Proper home safety requires adequate lighting to prevent falls, particularly along walkways. A single light fixture may not provide sufficient illumination and poses a risk.
B. A small area rug is placed at the front door: Loose rugs increase the risk of slips and falls. Safe home practices include securing rugs with nonslip backing or removing them entirely.
C. The batteries in the smoke alarms are changed annually: Smoke alarm batteries should be checked and replaced more frequently, typically every 6 months, to ensure proper function. Annual replacement alone may not be sufficient.
D. The water heater is set at 54° C (129.2° F): Setting the water heater at or below 54° C helps prevent scald injuries while providing adequate hot water. This demonstrates the client’s understanding of home safety measures.
Correct Answer is C
Explanation
Rationale:
A. The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication: A pain level of 2 indicates adequate pain control following surgery, showing that the prescribed analgesic regimen is effective. This finding does not require reporting.
B. The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter: A urine output of 50 mL/hr is within normal limits and indicates adequate renal perfusion. This finding suggests that kidney function and fluid balance are appropriate after surgery.
C. The client has a wound dressing saturated with sanguineous drainage after it was reinforced: Saturation of the surgical dressing with sanguineous drainage can indicate active bleeding or hemorrhage. Because this exceeds normal postoperative drainage and persists after reinforcement, it requires immediate notification of the provider.
D. The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied: An oxygen saturation of 96% indicates effective oxygenation and a positive response to therapy. This finding is within normal range and does not signal a complication.
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