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 A

Explanation

An acute asthma attack is a sudden worsening of asthma symptoms, such as coughing, wheezing, tightness in the chest, and difficulty breathing. These symptoms happen because the airways in the lungs become narrow, irritated, swollen, and produce excess mucus.

An asthma attack can be triggered by various factors, such as allergic reactions, respiratory infections, tobacco smoke, cold air, and exercise. These triggers cause the immune system to react and release chemicals that cause inflammation and constriction of the airways.

Based on this information, the best answer to the question is a. Inability to exhale retained carbon dioxide. This is because during an asthma attack, the narrowed airways make it harder to exhale the air from the lungs, which leads to a buildup of carbon dioxide in the blood. This can worsen the symptoms and cause acidosis, a condition where the blood becomes too acidic.

The other options are not correct because:

b. Acute loss of alveolar elasticity is not a cause of asthma attacks, but a consequence of chronic obstructive pulmonary disease (COPD), a different lung condition that involves damage to the alveoli, the tiny air sacs in the lungs.
c. Decreased responsiveness of airways to allergens is not a cause of asthma attacks, but a goal of asthma treatment. Asthma medications aim to reduce the sensitivity and inflammation of the airways to prevent or reduce the frequency and severity of asthma attacks.
d. Suppressed bronchiolar inflammatory response is not a cause of asthma attacks, but a potential side effect of some asthma medications, such as corticosteroids. These drugs can suppress the immune system and increase the risk of infections in the airways.

A. Creatinine 0.8 mi/dl. B. Weight gain 1.1 kg (2.4 lb) in 24 hr C. Peripheral pulses 2+ bilaterally D. Urine specific gravity 1.045

Correct Answer is B

Explanation

Weight gain in a short period of time indicates fluid retention, which can worsen the client's condition and lead to complications such as pulmonary edema and hypertension. The nurse should report this finding to the provider and monitor the client's fluid balance and electrolytes.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?

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 teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

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)?

A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching?

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients?

A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?