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
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Correct Answer is A
Explanation
The nurse should assess the client's gag reflex before allowing oral intake to prevent aspiration. The client's throat may be numb after a bronchoscopy, which is a procedure that uses a thin tube with a camera and light to examine the lungs and airways . The other actions are important but not the priority.
Correct Answer is B
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Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii, which can be transmitted by contact with cat feces or eating undercooked meat containing cysts. The nurse should ask about the client's exposure to cats or cat litter, as this is a risk factor for acquiring toxoplasmosis, especially in immunocompromised individuals.
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