A nurse in an emergency department is caring for a client who is to receive tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. In which order should the nurse complete the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Weigh the client.

Check for contraindications.

Administer the tPA.

Transfer the client to the CCU.

Answer and Explanation

The Correct Answer is B,A,C,D

The nurse should first check for contraindications to tPA, such as hemorrhagic stroke, recent surgery, bleeding disorder, or uncontrolled hypertension. Then, the nurse should weigh the client to calculate the correct dose of tPA based on body weight. Next, the nurse should administer the tPA within three hours of symptom onset to improve the chances of recovery. Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and possible complications.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A low potassium level (hypokalemia) can increase the risk for digoxin toxicity because it enhances the binding of digoxin to cardiac cells and increases its effects on cardiac contractility and electrical conduction. The nurse should monitor the client's potassium level and administer potassium supplements as prescribed if needed. The other electrolytes are not directly related to digoxin toxicity.

A. Latex B. Anesthetics C. Adhesive tape D. Povidone-iodine

Correct Answer is A

Explanation

Bananas are one of the fruits that contain proteins similar to those found in natural rubber latex, which can cause an allergic reaction in some people. This is called latex-fruit syndrome and can also occur with other fruits such as avocado, kiwi, chestnut, and papaya. The client should inform the surgical team about their banana allergy and avoid contact with latex products such as gloves, catheters, syringes, and bandages.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity?

Correct Answer is D

Explanation

A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances?

Correct Answer is A

Explanation

A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition?

A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an indication that the medication is effective?

A nurse is providing discharge teaching for a client who has osteomyelitis in the left leg. Which of the following findings should the nurse identify as requiring a referral?

A nurse is caring for a client following a below-the-knee amputation. The client states, "My life is over." Which of the following responses should the nurse make?

A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon?

A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk?

A nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify that which of the following rhythms indicates bradycardia?

A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect?