The nurse is caring for a client who has had a stroke and who has received tissue plasminogen activator (t-PA) on admission. The family member requests to bring in a razor for the client to use. Which response from the family would indicate an understanding teaching related to t-PA? The family member states, "I will

be careful with the straight razor."

insist the nurse use multiple razor blades."

bring in an electric razor for nurse to use for shaving."

bring in disposable razors blades to use for, shaving."

Answer and Explanation

The Correct Answer is C

A.   This response shows some awareness but does not indicate a sufficient understanding of the risks. Straight razors can pose a significant risk of cuts and bleeding, especially in a patient who has received t- PA, which can increase the likelihood of bleeding.
B.   This response suggests a misunderstanding. Using multiple razor blades does not inherently reduce the risk of bleeding and could increase the chance of cuts or nicks. This response does not indicate an appropriate understanding of safety precautions related to t-PA.
C.   This response indicates an understanding of safety precautions. Electric razors are safer for clients who are at risk of bleeding because they do not have sharp blades that can easily cause cuts. This choice minimizes the risk of injury while allowing for personal grooming.
D.   While disposable razors may seem convenient, they still carry a risk of cuts and bleeding. This response does not reflect a full understanding of the precautions necessary for a client who has received t-PA, as it does not prioritize safety in the same way that using an electric razor does.

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Correct Answer is C

Explanation

A. While the nursing student may assist with feeding, the nurse should always assess the client's swallowing ability and provide direct supervision to ensure the client's safety.
B. Placing food on the affected side of the mouth can increase the risk of aspiration. The food should be placed on the unaffected side of the mouth.
C. Distractions can impair the client's ability to focus on swallowing and increase the risk of aspiration. A quiet environment can help the client concentrate on eating.
D. The head of the bed should be elevated to at least 30 degrees during and after feeding to reduce the risk of aspiration.

A. reduce the risk of blood vessel spasm. B. prevent platelet aggregation. C. dissolve the blood clot. D. prevent infection in the brain.

Correct Answer is C

Explanation

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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ABG Value	Normal Range
PH	7.35-7.45
PaCO2	35-45 mm Hg
HCO3-	22-26 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

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Naxlex Comprehensive Predictor Exams

The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?

Correct Answer is C

Explanation

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:

Correct Answer is C

Explanation

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