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 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.

A. Decreased urinary output B. Increased heart rate C. Increased potassium level D. Decreased blood pressure

Correct Answer is D

Explanation

Valsartan is an angiotensin II receptor blocker that lowers blood pressure by blocking the vasoconstrictive and aldosterone-secreting effects of angiotensin II. Loweringblood pressure reduces the workload of the heart and improves cardiac function in patients with heart failure . Decreased urinary output, increased heart rate, and increased potassium level are not expected outcomes of valsartan therapy and may indicate worsening of heart failure or adverse effects of the medication.

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Naxlex Comprehensive Predictor Exams

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 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?

Correct Answer is D

Explanation

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 providing teaching to a client who has left-sided heart failure. Which of the following manifestations should the nurse include in the teaching?

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 for a positive Chvostek's sign following a thyroidectomy. Which of the following areas on the client's head should the nurse tap to assess the client for tetany?

A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity?

A nurse is caring for a client who has developed a heart rate of 38/min and reports tremors and feeling faint. Which of the following medications should the nurse anticipate administering?

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 in the emergency department admitted a client who is having a myocardial infarction. The client has been placed on the heart monitor. Which of the following electrocardiogram strips is indicative of a myocardial infarction?