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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["7"]
Explanation
(desired dose * volume of solution) / (concentration of drug * time) = rate.
For an infusion of 7 units per hour with a concentration of 100 units in 100 mL, the calculation would be: (7 units/hour * 100 mL) / (100 units * 1 hour) = 7 mL/hour.
Therefore, the nurse should set the IV pump to 7 mL per hour to deliver a continuous infusion of insulin at the prescribed rate.
Correct Answer is ["C","D"]
Explanation
A. Using humidifiers can help maintain moisture in the air, which is beneficial if the client is experiencing dry mucous membranes or respiratory discomfort, especially due to chemotherapy. However, while this can be helpful, it’s not the most critical teaching point compared to other options related to infection risk or symptoms monitoring.
B. While engaging in stress-reducing activities is important for overall well-being, gardening may pose specific risks for a client with AML, particularly concerning exposure to soil and potential pathogens. Activities should be carefully considered to avoid any risks of infection or physical strain.
C. Clients with AML, especially those undergoing chemotherapy, have a higher risk of infections due to neutropenia (low white blood cell count). A fever of 100.2°F or higher can be a sign of infection and requires prompt medical evaluation. Thus, this is a crucial point for the client to understand.
D. Fresh vegetables that are not cooked or peeled can harbor bacteria and other pathogens that could pose a risk of infection, especially in immunocompromised patients. Clients undergoing chemotherapy should avoid raw foods that can increase the risk of infections.
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