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Patient Data

Exhibits

The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.
What interdisciplinary team member(s) should assist the client in recovery? Select all that apply.

Case Manager

Occupational Therapist

Speech Therapist

Respiratory Therapist

Chief Nursing Officer

Medical Assistant

Pharmacy Technician

Physical Therapist

Answer and Explanation

Correct Answer : A,B,C,H

A.   A case manager can coordinate the overall care plan, ensuring the client receives appropriate services and support during recovery and discharge planning.
B.   An occupational therapist can help the client regain the ability to perform activities of daily living (ADLs) and improve fine motor skills affected by the stroke.
C.   A speech therapist can assist the client with speech and language difficulties, as well as swallowing issues that may have resulted from the stroke.
D.   A respiratory therapist is typically involved if there are respiratory issues, which are not indicated in this case.
E.   A chief nursing officer provides leadership and oversight roles, and not direct patient care.
F.   A medical assistant is typically involved in basic clinical tasks but not in specialized stroke recovery.
G.   A pharmacy technician fills prescriptions but doesn’t directly participate in client rehabilitation.
H.   A physical therapist can help the client improve strength, balance, and mobility, which are often impaired after a

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

A. placing all client belongings out of reach (A) does not promote safety as it may lead the client to attempt to get up unassisted to retrieve their items, increasing the risk of falls.
B. Instructing the client to call before getting up ensures that assistance is provided, preventing falls due to potential weakness or balance issues.
C. Initiating the use of a bed alarm helps in monitoring the client's movements, which is crucial in preventing falls, especially when the client might have impaired mobility.
D. Completing a swallow study before giving anything by mouth is essential to assess the risk of aspiration, which can be heightened due to possible swallowing difficulties post- stroke.
E. Placing the client in a room near the elevator does not directly promote safety; it could be beneficial for logistical reasons but does not address the client's immediate safety needs.
F. Providing a call button within reach allows the client to alert staff promptly if they need assistance, thus reducing the risk of injury.

A. IV 0.9% normal saline continuous infusion at 100 B. Daily weights C. Calculation of intake and output D. IV potassium sparing diuretic E. Continuous pulse oximetry monitoring F. Electrocardiogram monitoring

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A. Given the client's chronic kidney disease and the risk of fluid overload, a high rate of normal saline infusion may not be appropriate without careful assessment and specific indication from the healthcare provider.
B. Monitoring daily weight is essential in managing fluid balance and assessing for potential fluid overload, especially in a child with chronic kidney disease.

C. Accurate measurement of intake and output is crucial in managing fluid balance and monitoring kidney function, particularly in a patient with a history of acute kidney injury and chronic kidney disease.
D. The client already has an elevated potassium level, and administering a potassium-sparing diuretic could worsen hyperkalemia, leading to dangerous cardiac complications.
E. Continuous monitoring of oxygen saturation is important due to the presence of bibasilar infiltrates on the chest X-ray, which could indicate a potential respiratory issue.
F. ECG monitoring is indicated due to the elevated potassium level (5.3 mEq/L), which can cause cardiac arrhythmias. The irregular heart rate further supports the need for ECG monitoring.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Each row and each column must have at least one, but may have more than one, response option selected. Intervention: Promotes safety/ Does not promote safety

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Patient Data Exhibits The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record. Nursing Action: Indicated/ Contraindicated

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

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