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 B

Explanation

Rationale:
A. "Avoid sexual intercourse for 7 days after receiving treatment.": HPV infections often persist in epithelial tissue even after visible lesions are treated, meaning transmission can still occur. Avoiding sexual contact for only 7 days does not eliminate the risk of spreading the virus.

B. "Obtain all recommended immunizations.": Receiving the HPV vaccine is the most effective method of preventing sexual transmission. The vaccine protects against high-risk HPV strains associated with cervical, anal, and oropharyngeal cancers, as well as genital warts. It is most effective when administered before sexual activity begins.

C. "Apply imiquimod ointment to any perineal ulcers.": Imiquimod is used to treat external genital warts caused by HPV, not perineal ulcers. Its use does not prevent infection or transmission and should only be applied to intact wart tissue under provider supervision.

D. "Undergo laser therapy to remove any lesions.": Laser therapy can remove visible warts but does not eradicate the virus itself. While it reduces the number of infectious lesions, HPV can still be transmitted through microscopic viral shedding even after lesion removal.

A. "Purchasing more expensive items will improve quality health outcomes." B. "Preventing readmissions will decrease overutilization of services." C. "Planning a 10-year budget will ensure cost-effective care." D. "Hiring travel nurses is an effective method of cost containment."

Correct Answer is B

Explanation

Rationale:
A. "Purchasing more expensive items will improve quality health outcomes.": Higher cost does not necessarily correlate with better outcomes. Cost-effectiveness focuses on achieving optimal results while minimizing unnecessary expenses, not simply purchasing pricier items.

B. "Preventing readmissions will decrease overutilization of services.": Reducing hospital readmissions prevents unnecessary use of healthcare resources, lowers costs, and improves patient outcomes. Effective discharge planning, patient education, and follow-up care are strategies that support cost-effective care.

C. "Planning a 10-year budget will ensure cost-effective care.": Long-term budgeting aids financial planning but does not directly guarantee cost-effective care. Cost-effectiveness is achieved by evaluating interventions, resource utilization, and outcomes continuously.

D. "Hiring travel nurses is an effective method of cost containment.": Travel nurses typically have higher hourly rates than permanent staff, which can increase costs. While they provide staffing flexibility, this strategy is not considered cost-effective for routine staffing needs.

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