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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Washing hands for a total of 20 seconds is recommended by the CDC as part of proper hand hygiene to prevent the spread of germs.
Choice B reason: Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.
Choice C reason: Keeping hands below elbows when rinsing is the correct procedure to prevent water from running down the arms onto the cleaned hands.
Choice D reason: Lathering using a circular movement is a recommended technique to ensure all surfaces of the hands are cleaned thoroughly.
Correct Answer is B
Explanation
Choice A reason: Measuring urinary output is important for monitoring renal function, especially when using medications like morphine, but it is not the most critical intervention in this context.
Choice B reason: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain.
Choice C reason: Monitoring for a depressed respiratory rate is crucial when a patient is on morphine, but the priority is to manage pain effectively as the client transitions to oral analgesics.
Choice D reason: Education on dietary needs is important for long-term recovery, but immediate pain management is a higher priority in the postoperative period.
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