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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Compartment syndrome is a condition in which increased pressure within a confined space compromises blood flow and tissue perfusion, leading to ischemia and necrosis. It can occur after trauma, fracture, or casting of an extremity. The early signs of compartment syndrome include intense pain with movement that is not relieved by analgesics or elevation, paresthesia, pallor, and decreased sensation and motor function of the affected limb. The late signs include absent distal pulses, cyanosis, coldness, and paralysis. Therefore, option A is correct.
Correct Answer is A
Explanation
Bananas are one of the fruits that contain proteins similar to those found in natural rubber latex, which can cause an allergic reaction in some people. This is called latex-fruit syndrome and can also occur with other fruits such as avocado, kiwi, chestnut, and papaya. The client should inform the surgical team about their banana allergy and avoid contact with latex products such as gloves, catheters, syringes, and bandages.
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