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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. "Avoid consuming grapefruit juice while taking this medication.": Grapefruit juice inhibits the cytochrome P450 enzyme system in the liver, leading to increased serum levels of nifedipine. This can potentiate adverse effects such as hypotension, dizziness, and tachycardia.

B. "Your magnesium level will be monitored while taking this medication.": Nifedipine, a calcium channel blocker, does not significantly affect magnesium levels. Monitoring magnesium is more relevant for clients receiving magnesium sulfate.

C. "This medication can cause changes in thyroid function.": Nifedipine has no known effects on thyroid hormones or gland function. Drugs affecting thyroid function include amiodarone or lithium, not calcium channel blockers like nifedipine.

D. "This medication can cause an increase in blood glucose levels.": Nifedipine does not alter glucose metabolism. Medications such as corticosteroids and thiazide diuretics are more likely to cause hyperglycemia, whereas nifedipine’s primary effects involve smooth muscle relaxation and vasodilation.

A. "I will plan to continue taking this medication for at least 5 years." B. "My provider wants me to take this medication for 2 weeks before I try to quit drinking." C. "I should avoid over-the-counter medications that contain alcohol." D. "I will need to get a monthly injection of this medication."

Correct Answer is C

Explanation

Rationale:
A. "I will plan to continue taking this medication for at least 5 years.": Disulfiram therapy is not prescribed for a fixed duration such as 5 years. The length of treatment depends on the client’s motivation and response, typically continuing until long-term abstinence is maintained.

B. "My provider wants me to take this medication for 2 weeks before I try to quit drinking.": Disulfiram must be started only after the client has abstained from alcohol for at least 12 hours, not before quitting. Taking it while alcohol is still in the system can trigger severe reactions such as flushing, nausea, vomiting, and hypotension.

C. "I should avoid over-the-counter medications that contain alcohol.": Even small amounts of alcohol—such as in cough syrups, mouthwash, or sauces—can cause a dangerous disulfiram-alcohol reaction. Clients must avoid all alcohol-containing products.

D. "I will need to get a monthly injection of this medication.": Disulfiram is taken orally, usually once daily, and does not come in injectable form. The injectable medication used for alcohol dependence is naltrexone (Vivitrol).

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new prescription for nifedipine. Which of the following statements should the nurse include?

Correct Answer is A

Explanation

A nurse is providing medication teaching about disulfiram for a client who has alcohol use disorder. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory results for a female client who is receiving furosemide and digoxin. Which of the following findings should the nurse recognize increases the client's risk for developing digoxin toxicity?

A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan care?

A nurse is calculating the BMI of a client who has a weight of 75 kg (165.3 lb) and a height of 1.8 m (5 ft 9 in). Which of the following values should the nurse calculate as the client's BMI?

A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?

A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?

A nurse is caring for a client who has been on hemodialysis for the past 5 years. The client is refusing hemodialysis and says, "I'm tired of wasting my life; I would rather die."Which of the following statements should the nurse make?

A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?