An RN is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching?

"tPA should be administered within 12 hrs of the onset of a stroke."

"tPA is administered by intraarterial infusion."

"tPA is administered IV."

"PA requires BP monitoring during and 24 hrs after the treatment."

Answer and Explanation

The Correct Answer is A

A.   tPA (tissue plasminogen activator) should be administered within 3 to 4.5 hours of the onset of ischemic stroke symptoms, not 12 hours. Administering it after this window increases the risk of complications such as bleeding.
B.   tPA is administered by intraarterial infusion is true, but it refers to a specific technique for certain stroke types.
C.   tPA is administered IV is correct for intravenous administration in many cases of ischemic stroke.

D.   tPA requires BP monitoring during and 24 hrs after the treatment is accurate as blood pressure control is critical when administering tPA.

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Correct Answer is D

Explanation

A. BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B. BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C. BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D. The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

A. Restrict head movement. B. Apply cool compresses. C. Keep both eyes patched. D. Eye drops to constrict the pupils will be prescribed.

Correct Answer is A

Explanation

A. After retinal detachment surgery, it is essential to restrict head movement to avoid further damage to the retina or to ensure proper healing post-surgery.
B. Apply cool compresses is not typically recommended before or after retinal detachment surgery, as it could cause discomfort or worsen symptoms.
C. Keep both eyes patched is not necessary unless specifically instructed by the surgeon.
D. Eye drops to constrict the pupils are generally used after surgery but are not a preoperative measure.

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An RN is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Correct Answer is D

Explanation

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

Correct Answer is A

Explanation

Which method of measurement is the gold standard for obtaining intracranial pressures?

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