Twenty minutes after the onset of symptoms, an adult client presents to the emergency department with slurred speech and right-sided weakness. After a computerized tomography (CT) scan reveals a non-hemorrhagic stroke, the nurse administers alteplase. Which assessment finding warrants immediate intervention?

Headache with blurred vision.

Lower extremity edema.

Paroxysmal supraventricular tachycardia.

Frequent premature ventricular contractions.

Answer and Explanation

The Correct Answer is A

Choice A reason: A headache with blurred vision following alteplase administration could indicate intracranial hemorrhage, which requires immediate intervention.

Choice B reason: Lower extremity edema is not typically an immediate concern post-alteplase administration unless it indicates a deep vein thrombosis.

Choice C reason: Paroxysmal supraventricular tachycardia requires monitoring, but it is not as urgent as a headache with blurred vision, which could signify a life-threatening complication.

Choice D reason: Frequent premature ventricular contractions should be monitored, but they are not as critical as a headache with blurred vision post-alteplase.

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Correct Answer is C

Explanation

Choice A reason: Obtaining vital signs every 2 hours is standard postoperative care but does not specifically address the needs of a client recovering from retinal detachment surgery.

Choice B reason: While deep breathing and coughing exercises are important postoperative interventions, they are not specific to the care of a client after retinal detachment surgery.

Choice C reason: Providing an eye shield for sleep helps to protect the eye from accidental rubbing or pressure, which is critical after retinal surgery.

Choice D reason: Teaching a family member to administer eye drops is important for ongoing care but is not as immediately critical as protecting the eye from injury.

A. Walk frequently during recovery. B. Advance diet from clear liquids to full liquid. C. Anticipate weight loss will continue even with normal diet. D. Begin taking supplements per the healthcare provider's orders. E. Expect immediate return of ovulation. F. Start with room temperature water. G. Encourage three large meals a day.

Correct Answer is ["A","B","D","F"]

Explanation

Choice A reason: Walking frequently during recovery is essential for preventing blood clots, improving circulation, and aiding in the healing process. It is recommended for patients to start with short, frequent walks and gradually increase the distance as tolerated. This helps to enhance physical activity and supports weight loss maintenance post-surgery.
Choice B reason: After bariatric surgery, patients are typically started on a clear liquid diet and then advanced to full liquids before progressing to pureed foods and eventually solid foods. This gradual progression is necessary to allow the stomach to heal and to avoid complications such as leaks or obstructions at the surgical site.
Choice D reason: Patients who have undergone bariatric surgery are at risk for nutritional deficiencies due to the reduced intake and absorption of nutrients. Therefore, taking prescribed vitamin and mineral supplements is crucial to prevent deficiencies and ensure adequate nutrition.
Choice F reason: Starting with room temperature water can help prevent discomfort and gastrointestinal symptoms that may occur when drinking cold fluids after surgery. Room temperature fluids are generally better tolerated in the immediate postoperative period.
Choice C reason: While weight loss is expected after bariatric surgery, it is not accurate to anticipate that weight loss will continue with a normal diet. Patients must adhere to a specific postoperative diet and lifestyle changes to ensure continued weight loss and avoid weight regain.
Choice E reason: Ovulation and fertility can be affected by significant weight loss; however, it is not appropriate to expect an immediate return of ovulation post-surgery. Fertility changes can vary from person to person and may take time.
Choice G reason: Encouraging three large meals a day is contrary to the recommended dietary guidelines post-bariatric surgery. Patients are advised to eat small, frequent meals to accommodate the reduced stomach capacity and to prevent symptoms of dumping syndrome.
Choice H reason: Dietician appointments are not optional but are a critical component of postoperative care. Regular follow-up with a dietician ensures that patients receive personalized nutritional guidance and support as they adjust to their new dietary habits.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For a client who has undergone surgery to repair a retinal detachment in the left eye, which intervention should the nurse implement during the postoperative period?

Correct Answer is C

Explanation

Patient Data Exhibits The nurse reviews the client data. What discharge education should the nurse provide? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Patient Data: Exhibits Review H and P and laboratory results. Based on the laboratory data, the client has dropdown related to dropdown

A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care?

A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?