The nurse is caring for a client who had a thrombotic stroke in the Emergency Department. It has been less than 3 hours since the onset of symptoms. The rationale for using tissue plasminogen activator (t-PA) for this client is to:

reduce the risk of blood vessel spasm.

prevent platelet aggregation.

dissolve the blood clot.

prevent infection in the brain.

Answer and Explanation

The Correct Answer is C

A.   While blood vessel spasms can occur after a stroke, t-PA does not directly affect them.
B.   Platelet aggregation is the process by which platelets stick together to form a clot. t-PA dissolves clots, but it does not prevent their formation.
C.   Tissue plasminogen activator (t-PA) is a medication that can dissolve blood clots. In the case of a thrombotic stroke, a blood clot has blocked blood flow to the brain. By dissolving the clot, t-PA can restore blood flow and limit brain damage.
D.   t-PA does not have any direct effect on the risk of infection in the brain.

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Correct Answer is D

Explanation

A. While it's true that ulcers can be a serious complication of PAD and require careful management, exercise is generally encouraged in patients with PAD as long as it is safe and supervised. Patients should consult their healthcare provider about appropriate exercise, but not exercising altogether can worsen their condition.
B. Buying shoes in the afternoon is advisable because feet can swell throughout the day. It helps ensure a better fit and reduces the risk of blisters or skin breakdown, which is particularly important for clients with PAD.
C. This statement is generally correct, as dangling the legs can help improve circulation in some cases. Clients with PAD often experience relief when their legs are in a dependent position, as it may help increase blood flow to the extremities. However, they should also be encouraged to avoid prolonged periods of sitting.
D. This statement may indicate a misunderstanding. Compression stockings are typically used for venous issues rather than arterial diseases like PAD. In patients with PAD, wearing compression stockings may not be appropriate and could potentially compromise arterial blood flow.

Correct Answer is ["14"]

Explanation

154 lbs ÷ 2.2 lbs/kg = 70 kg

20 units/kg * 70 kg = 1400 units

1400 units ÷ 25,000 units/250 mL = 14 mL

Therefore, the nurse will administer 14 mL of Heparin.

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The nurse is caring for a client who had a thrombotic stroke in the Emergency Department. It has been less than 3 hours since the onset of symptoms. The rationale for using tissue plasminogen activator (t-PA) for this client is to:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with peripheral arterial disease. Which statement, by the client, indicates that they need additional teaching?

Correct Answer is D

Explanation

A patient is ordered 20 unit/kg IV bolus of Heparin. The patient weighs 154 lbs. Heparin is supplied 25,000 units/250 mL. How many mL will the nurse administer? (round to the nearest whole number)

Correct Answer is ["14"]

Explanation

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