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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should measure the client's blood pressure first, as sinus bradycardia can cause hypotension and decreased perfusion to vital organs. The nurse should assess the client's hemodynamic status and symptoms before initiating any interventions that may affect their heart rate or rhythm. The other options may be appropriate depending on the severity of the bradycardia and its underlying cause, but they are not the first priority.
Correct Answer is D
Explanation
The nurse should instruct the client to trim toenails straight across to prevent ingrown toenails and infection. The nurse should also advise the client to inspect the feet daily for any signs of injury or ulceration, to avoid applying lotion between the toes as this can cause maceration and fungal growth, and to avoid soaking the feet as this can dry out the skin and increase the risk of injury.
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