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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Rationale:
A. Transfer on the client's weaker side when moving a client from a bed to a chair: Clients should be moved toward their stronger side to facilitate participation and reduce strain on both the client and the nurse. Transferring toward the weaker side increases risk of injury and reduces stability.

B. Raise the head of the bed when transferring a client from a bed to a stretcher: Raising the head of the bed does not directly enhance safe body mechanics or ergonomic principles during a transfer. Proper lifting techniques and devices are more critical for preventing injury.

C. Use a lateral transfer device when moving a client from a bed to a stretcher: Using a lateral transfer device, such as a sliding board or transfer sheet, minimizes manual lifting, reduces musculoskeletal strain, and follows ergonomic principles. It is a key safety strategy for both the client and healthcare staff.

D. Use a pillow underneath the client's head when repositioning a client in bed: Placing a pillow under the head supports comfort and alignment but does not relate to ergonomic principles or safe lifting techniques. Ergonomics focuses on body mechanics, positioning, and injury prevention for caregivers.

A. "Supplement breastfeedings with water every 12 hours." B. "Limit the time your infant feeds to 10 minutes on each breast." C. "Begin each feeding using the same breast." D. "Offer your infant the breast when he shows signs of hunger."

Correct Answer is D

Explanation

Rationale:
A. "Supplement breastfeedings with water every 12 hours.": Breastfed infants do not require water supplementation because breast milk provides adequate hydration. Giving water can reduce milk intake, interfere with nutrition, and increase the risk of electrolyte imbalance.

B. "Limit the time your infant feeds to 10 minutes on each breast.": Feeding duration should be guided by the infant’s cues rather than a strict time limit. Limiting feeds can prevent the infant from receiving the hindmilk, which is richer in fat and essential for growth.

C. "Begin each feeding using the same breast.": Alternating the starting breast for each feeding helps ensure equal stimulation and milk production in both breasts. Starting with the same breast consistently may lead to uneven milk supply.

D. "Offer your infant the breast when he shows signs of hunger.": Responsive, cue-based feeding supports adequate nutrition, growth, and bonding. Feeding on demand—such as rooting, sucking on hands, or fussiness—helps establish and maintain milk supply and meets the infant’s needs effectively.

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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?

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