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 D

Explanation

The client has hypokalemia, which is a low level of potassium in the blood. Hypokalemia can cause cardiac arrhythmias, which can be life-threatening. The nurse should initiate cardiac monitoring first to assess the client's heart rhythm and rate, and intervene if any abnormalities are detected. Administering an IV potassium drip is an appropriate intervention for hypokalemia, but it is not the first priority. Listening to the client's bowel sounds and checking the client's hand grasps are also relevant assessments for hypokalemia, as it can cause decreased bowel motility and muscle weakness, but they are not as urgent as cardiac monitoring.

A. COPD B. rheumatoid arthritis C. Thalassemia D. Thrombocytopenia

Correct Answer is D

Explanation

Thrombocytopenia is a condition where the blood has a low platelet count, which can impair blood clotting and increase the risk of bleeding. Heparin is an anticoagulant that prevents blood clots from forming or growing, but it can also cause or worsen thrombocytopenia and bleeding.

Therefore, heparin is contraindicated for clients who have thrombocytopenia or are at risk of developing it. The other conditions are not contraindications to receiving heparin.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

Correct Answer is D

Explanation

A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permanent pacemaker?

A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?

A nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?