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 C

Explanation

Metformin is an oral medication used to treat type 2 diabetes. It should be withheld before and after a procedure that requires IV contrast dye because it can increase the risk of lactic acidosis, a serious condition caused by the buildup of lactic acid in the blood. The other medications are not contraindicated with IV contrast dye and can be given as scheduled.

A. Take an antacid 30 min before taking the medication. B. Monitor heart rate once daily. C. Drink 2 to 3 L of fluids daily. D. Take a laxative to prevent constipation.

Correct Answer is C

Explanation

Ciprofloxacin is an antibiotic used to treat different types of bacterial infections, including urinary tract infections. Drinking plenty of fluids can help flush out bacteria from the urinary tract and prevent dehydration. Taking an antacid can reduce the absorption of ciprofloxacin and make it less effective.

Monitoring heart rate is not necessary unless the client has a history of cardiac problems or is taking other medications that affect the heart . Taking a laxative can cause diarrhea, which can worsen dehydration and electrolyte imbalance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is performing skin cancer screening on a group of clients. Which of the following findings should the nurse identify as an indication of melanoma?

A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

A nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

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?

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

A nurse is reviewing the following ABG results for a postoperative client: pH 7.27, PaCO2 49 mm Hg, PaO2 65 mm Hg, HCO 22 mEq/L. The nurse should interpret the findings as which of the following imbalances?

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?

A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?