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

The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.

A. Decreased bowel sounds B. Increased central venous pressure C. Confusion D. Hyperreflexia

Correct Answer is C

Explanation

A serum sodium level of 120 mEq/L indicates hyponatremia, which is a condition where there is an excess of water relative to sodium in the body fluids. Hyponatremia can cause various neurological symptoms such as confusion, lethargy, seizures, coma, and death.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is assessing a client who has a serum sodium level of 120 mEq/L. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?

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A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider?

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