The nurse is caring for client who has had a stroke and who has received tissue plasminogen activator (t-PA) 4 hours ago in the emergency department. During the nurse's initial assessment, which of the following signs and symptoms are indications of a complication post thrombolytic therapy? (SELECT ALL THAT APPLY)

Fever and Cardiac dysrhythmias

Elevated BP & patient reports headache

Positive Babinski’s sign

Patient has vomited once and reports nausea

decreased level of consciousness

Answer and Explanation

Correct Answer : B,D,E

A. Fever and cardiac dysrhythmias are not specific complications of tissue plasminogen activator (t-PA) therapy. While they can occur after a stroke or as a general response to illness, they are not the primary indicators of complications related to thrombolytic therapy.

B. An elevated blood pressure combined with a headache could indicate a hemorrhagic transformation, which is a serious complication after t-PA administration. Thrombolytic therapy increases the risk of bleeding, and these symptoms may signal intracranial hemorrhage.

C. A positive Babinski's sign (extensor plantar response) is often seen in stroke patients as a neurological finding, but it is not specifically an indication of a complication from t-PA therapy. It is more reflective of the brain injury or stroke itself rather than the medication.

D. Nausea and vomiting can be signs of increased intracranial pressure (ICP), which could result from hemorrhage following t-PA therapy. This is a critical sign that requires immediate evaluation to rule out complications such as bleeding.

E. A decreased level of consciousness is a significant red flag and may indicate cerebral hemorrhage or another serious complication related to the administration of t-PA. Monitoring for changes in neurological status is crucial following thrombolytic therapy.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. While pain is expected after any surgery, the focus of preoperative teaching should be on immediate post-operative expectations such as the presence of a chest tube, which is more critical for the nurse to prepare the client for. Pain management will be addressed postoperatively.
B. After a lobectomy, a chest tube is commonly placed to help drain excess air, fluid, or blood from the pleural space and prevent pneumothorax or other complications. This is a key part of the post-operative care for lung surgery.
C. Pulmonary function tests may be done before surgery to assess lung capacity and function, but they are not typically expected immediately after a lobectomy unless specified by the physician.
D. A lobectomy involves the removal of a portion of the lung, and the incision is usually made between the ribs, not through the sternum. The incision is generally intercostal, meaning it’s made between the ribs, not through the chest bone.

Correct Answer is ["480"]

Explanation

Convert time to hours:
25 minutes ÷ 60 = 0.4167 hours

Step 2:
Use the formula:
Rate (mL/hr) = Volume (mL) ÷ Time (hr)

Rate = 200 mL ÷ 0.4167 hr ≈ 480 mL/hr

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure?

Correct Answer is B

Explanation

A client is ordered to receive a bolus of 200 mL of NSS in 25 minutes. At what rate should the nurse set the IV pump?

Correct Answer is ["480"]

Explanation

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