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 D

Explanation

Choice A reason: Heat and cold therapy can help manage symptoms but are not directly related to health promotion and teaching.

Choice B reason: Avoiding foods containing purine is more related to conditions like gout, not rheumatoid arthritis.

Choice C reason: Immobilization of affected joints is not a health promotion strategy and can actually worsen rheumatoid arthritis symptoms over time.

Choice D reason: Prevention through nutrition and exercise is a key component of health promotion and teaching for clients with rheumatoid arthritis, as it can help manage symptoms and improve overall health.

A. Assess for discomfort when the procedure is completed. B. Instruct the client to keep hands under the sterile field. C. Pour cleansing solution onto the sterile cloth field. D. Verify that the client has given informed consent.

Correct Answer is D

Explanation

Choice A reason: Assessing for discomfort is important, but it is not a safety intervention that should be implemented during the creation of a sterile field.

Choice B reason: Instructing the client to keep hands under the sterile field is not practical or safe, especially since the client is mildly confused and may not be able to follow such instructions.

Choice C reason: Pouring cleansing solution onto the sterile cloth field is part of the debridement process but does not directly relate to client safety.

Choice D reason: Verifying informed consent is crucial for client safety to ensure that the client understands the procedure and agrees to it, especially when the client is confused.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis?

Correct Answer is D

Explanation

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

Correct Answer is D

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

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

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome indicates that the program was effective?

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

After a partial gastrectomy, in addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform to prevent respiratory complications?