The nurse will include which intervention for the patient newly admitted with cellulitis of the right foot?

Encourage frequent ambulation

Maintain foot in a dependent position.

Apply warm, moist heat

Wrap the foot snugly in the blanket

Answer and Explanation

The Correct Answer is C

A.   Ambulation may worsen the condition as it could increase swelling or spread infection.
B.   This may increase swelling and should generally be avoided in cellulitis.
C.   This helps to improve circulation and reduce swelling in cellulitis.
D.   Wrapping the foot tightly could exacerbate swelling and discomfort.

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Correct Answer is D

Explanation

A. BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B. BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C. BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D. The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

A. "tPA should be administered within 12 hrs of the onset of a stroke." B. "tPA is administered by intraarterial infusion." C. "tPA is administered IV." D. "PA requires BP monitoring during and 24 hrs after the treatment."

Correct Answer is A

Explanation

A. tPA (tissue plasminogen activator) should be administered within 3 to 4.5 hours of the onset of ischemic stroke symptoms, not 12 hours. Administering it after this window increases the risk of complications such as bleeding.
B. tPA is administered by intraarterial infusion is true, but it refers to a specific technique for certain stroke types.
C. tPA is administered IV is correct for intravenous administration in many cases of ischemic stroke.

D. tPA requires BP monitoring during and 24 hrs after the treatment is accurate as blood pressure control is critical when administering tPA.

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The nurse will include which intervention for the patient newly admitted with cellulitis of the right foot?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Correct Answer is D

Explanation

An RN is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching?

Correct Answer is A

Explanation

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