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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Correct Answer is C

Explanation

The nurse should expect disequilibrium with movement if the client has impaired function of the vestibulocochlear nerve, as this nerve is responsible for hearing and balance. Deviation of the tongue from midline indicates impairment of the hypoglossal nerve (cranial nerve XII), loss of peripheral vision indicates impairment of the optic nerve (cranial nerve II), and inability to smell indicates impairment of the olfactory nerve (cranial nerve I).

A. Serum albumin level 3.9 g/dL B. Calcium level 11.5 mg/dL C. Output 200 mL more than intake over the past 12 hr D. Fasting blood glucose level 105 mg/dL.

Correct Answer is B

Explanation

A high calcium level (hypercalcemia) can indicate complications of TPN, such as bone demineralization, renal calculi, or metabolic alkalosis. The nurse should notify the provider of this finding and expect to adjust the TPN formula or administer fluids and diuretics to lower the calcium level. The other options are within normal or expected ranges for a client receiving TPN.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?

Correct Answer is C

Explanation

A nurse is caring for a client who has been receiving total parenteral nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider?

Correct Answer is B

Explanation

A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take?

A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?

A nurse is checking a client's ventilator settings. The nurse should understand that positive end- expiratory pressure has which of the following purposes?

A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?