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 C

Explanation

Ciprofloxacin is an antibiotic used to treat different types of bacterial infections, including urinary tract infections. Drinking plenty of fluids can help flush out bacteria from the urinary tract and prevent dehydration. Taking an antacid can reduce the absorption of ciprofloxacin and make it less effective.

Monitoring heart rate is not necessary unless the client has a history of cardiac problems or is taking other medications that affect the heart . Taking a laxative can cause diarrhea, which can worsen dehydration and electrolyte imbalance.

A. Intense pain with movement B. Bounding distal pulses C. Erythema of the toes D. Capillary refill less than 2 seconds

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.

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse in a provider's office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?

A nurse is caring for a client following a below-the-knee amputation. The client states, "My life is over." Which of the following responses should the nurse make?

A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?

A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have at the bedside?

A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider?

A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?