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 client who has thrombocytopenia and reports a nosebleed
A client who has left-sided paralysis and slurred speech from a prior stroke
A client who has multiple sclerosis and reports ataxia and vertigo
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%
The Correct Answer is D
Choice A rationale: A client with thrombocytopenia reporting a nosebleed may need intervention, but it is not an immediate concern unless severe bleeding is present.
Choice B rationale: A client with left-sided paralysis and slurred speech from a prior stroke may need attention, but their airway and oxygenation should take precedence.
Choice C rationale: A client with multiple sclerosis reporting ataxia and vertigo may need assessment and care, but their symptoms are not indicative of an immediate life-threatening situation.
Choice D rationale: A client with chronic obstructive pulmonary disease and an oxygen saturation of 89% requires immediate attention, as this indicates potential respiratory distress and hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,B,C,A
Explanation
Choice A rationale: Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and bleeding complications.
Choice B rationale: Then, the nurse should weigh the client to calculate the correct dose of tPA, which is based on body weight.
Choice C rationale: This comes after checking for the contraindications and weighing the client to determine the dose to be administered. The nurse should administer the tPA within 3 hours of symptom onset to dissolve the clot and restore blood flow to the brain.
Choice D rationale: The nurse should first check for contraindications to tPA, such as recent surgery, bleeding disorders, or uncontrolled hypertension.
Correct Answer is B
Explanation
Choice A rationale: Urticaria (hives) is not a direct contraindication to acupuncture.
Choice B rationale: Lymphedema is a contraindication to acupuncture, as it involves the insertion of needles, and there is a risk of exacerbating lymphatic congestion.
Choice C rationale: Mouth sores may not necessarily be a contraindication, but careful consideration is needed.
Choice D rationale: Headaches are not a contraindication to acupuncture, and acupuncture is sometimes used to manage headaches.
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