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 pressure ulcer is a localized injury to the skin and underlying tissue caused by prolonged pressure, shear, friction, or moisture.

Granulation tissue is new connective tissue and blood vessels that form on the surface of a wound during healing . It is usually dark red or pink in color and moist in appearance . Wound tissue that is firm to palpation may indicate edema, inflammation, or infection . Dry brown eschar is dead tissue that covers the wound and prevents healing . Light yellow exudate is a sign of wound infection or necrosis .

A. To deliver a set tidal volume B. To provide positive airway pressure during inspiration C. To control the rate of ventilations D. To prevent alveolar collapse

Correct Answer is D

Explanation

Positive end-expiratory pressure (PEEP) is a mode of mechanical ventilation that maintains a positive pressure in the airways at the end of expiration, preventing alveolar collapse and improving oxygenation. PEEP does not affect tidal volume, inspiratory pressure, or ventilation rate, which are determined by other ventilator settings.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

Correct Answer is D

Explanation

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

Correct Answer is D

Explanation

A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

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 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?

A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?

A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make?

A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? (Select all that apply.)

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?