A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

Start a labetalol drip to keep BP less than 140/90 mm Hg.

Keep the head of the bed elevated at least 30 degrees.

Begin tissue plasminogen activator (tPA) intravenously per protocol.

Infuse normal saline intravenously at 75 mL/hr.

Answer and Explanation

The Correct Answer is C

A. Start a labetalol drip to keep BP less than 140/90 mm Hg: This order is appropriate because it aims to lower the patient's blood pressure to a target range recommended for acute ischemic stroke management.

B. Keep the head of the bed elevated at least 30 degrees: This intervention is part of stroke management to prevent aspiration and improve cerebral perfusion.

C. Begin tissue plasminogen activator (tPA) intravenously per protocol: The nurse should question this order because tissue plasminogen activator (tPA) is contraindicated in patients with stroke who have had symptoms for more than 3 hours or have unknown time of onset, as in this case where the patient has been aphasic for 3 hours. Administering tPA in this situation could increase the risk of bleeding complications without providing benefit.

D. Infuse normal saline intravenously at 75 mL/hr: This order is appropriate for maintaining hydration and intravascular volume in the acute care setting.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. The patient's blood pressure (BP) is 144/90 mm Hg: While elevated blood pressure may contribute to the risk of intracerebral hemorrhage, the patient's current BP is not excessively high and may not be the most critical factor in this situation compared to other factors such as anticoagulant use.

B. The patient takes a diuretic because of a history of hypertension: While the patient's history of hypertension and diuretic use are relevant to their overall health status, they may not be the most immediate concern in the context of intracerebral hemorrhage.

C. The patient has atrial fibrillation and takes warfarin (Coumadin): This information is crucial as it indicates that the patient is anticoagulated, which can significantly impact the severity and management of intracerebral hemorrhage. Anticoagulant use increases the risk of bleeding and can worsen outcomes in cases of intracranial hemorrhage.

D. The patient's speech is difficult to understand: While difficulty with speech may indicate neurological impairment, it is not as immediately concerning as the patient's anticoagulant use, which increases the risk of bleeding complications and may require specific interventions such as reversal agents.

A. Call the health care provider if stools are tarry. B. Clopidogrel will reduce cerebral artery plaque formation. C. Clopidogrel will dissolve clots in the cerebral arteries. D. Monitor and record the blood pressure daily.

Correct Answer is B

Explanation

A. Call the health care provider if stools are tarry: This instruction is more relevant to medications such as aspirin or NSAIDs, which can increase the risk of gastrointestinal bleeding.
Clopidogrel, while also an antiplatelet medication, is less likely to cause gastrointestinal bleeding compared to aspirin.

B. Clopidogrel will reduce cerebral artery plaque formation: Clopidogrel is an antiplatelet
medication that inhibits platelet aggregation, thereby reducing the formation of blood clots and potentially slowing the progression of atherosclerosis by preventing further plaque formation.

C. Clopidogrel will dissolve clots in the cerebral arteries: While clopidogrel can help prevent the formation of new clots, it does not actively dissolve existing clots in the cerebral arteries. Its primary mechanism of action is to inhibit platelet aggregation and prevent clot formation.

D. Monitor and record the blood pressure daily: While monitoring blood pressure is important for managing cerebral atherosclerosis and reducing the risk of stroke, it is not directly related to the action of clopidogrel. Blood pressure management may involve lifestyle modifications and other medications but is not specific to clopidogrel administration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

Correct Answer is C

Explanation

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel?

Correct Answer is B

Explanation

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Which problem should the nurse expect for a patient who has a positive Romberg test result?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?