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
The client has neutropenia, which is a low number of neutrophils, a type of white blood cell that fights infection. The client is at risk for developing infections from bacteria and fungi that are normally present in the environment. Raw fruits may contain these microorganisms and should be avoided.
Contact isolation is not necessary for neutropenic clients, unless they have an active infection. Applying pressure to venipuncture sites for 10 min is a standard precaution for all clients, not specific to neutropenic clients. Moving the client to a negative pressure room is indicated for clients with airborne infections, not neutropenic clients.
Correct Answer is D
Explanation
A mastectomy is a surgical removal of one or both breasts, usually done to treat breast cancer. The nurse should respect the client's autonomy and provide factual information about the procedure, its benefits and risks, and possible alternatives . The nurse should also assess the client's readiness to learn, address any concerns or fears, and offer emotional support . Telling the client to get a second opinion may imply that the nurse does not trust the surgeon or doubts the necessity of the procedure.
Telling the client that they will be cancer-free if they have the procedure may be false or misleading, as there may be residual cancer cells or recurrence after surgery. Giving the client a list of other people who had the same procedure may violate confidentiality and may not be helpful or relevant to the client's situation.
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