41. A nurse in an emergency department is caring for a client who is to receive tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. In which order should the nurse complete the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Transfer the client to the CCU

Weigh the client

Administer the PA

Check for contraindications

Answer and Explanation

The Correct Answer is D,B,C,A

Choice A rationale: Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and bleeding complications.

Choice B rationale: Then, the nurse should weigh the client to calculate the correct dose of tPA, which is based on body weight.

Choice C rationale: This comes after checking for the contraindications and weighing the client to determine the dose to be administered. The nurse should administer the tPA within 3 hours of symptom onset to dissolve the clot and restore blood flow to the brain.

Choice D rationale: The nurse should first check for contraindications to tPA, such as recent surgery, bleeding disorders, or uncontrolled hypertension.

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Correct Answer is C

Explanation

Choice A rationale: Vasovagal bradycardia without syncope may not necessarily require a pacemaker.
Choice B rationale: Asymptomatic second-degree AV block may not always require a pacemaker, and the decision depends on the specific circumstances.
Choice C rationale: Complete AV block with rates slower than 40/min is an indication for the placement of a permanent pacemaker to restore adequate heart rate and rhythm.
Choice D rationale: Sinus tachycardia is not an indication for a pacemaker; it is a normal response to various stimuli.

A. Administer PRN pain medication. B. Check the client's urine output. C. Reposition the dent in bed D. Monitor the clients fluid intake

Correct Answer is B

Explanation

Choice A rationale: Administering PRN pain medication may be necessary, but assessing the cause of the pain is the priority.
Choice B rationale: Checking the client's urine output is the first action to assess for possible complications, such as clot retention or obstruction, which could cause lower abdominal pain.
Choice C rationale: Repositioning the client in bed may be considered after assessing urine output, depending on the findings.
Choice D rationale: Monitoring fluid intake is important but is not the immediate action needed to address the reported pain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permanent pacemaker?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon?.

A nurse is checking a client's ventilator settings. The nurse should understand that positive end-expiratory pressure has which of the following purposes?

A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?

A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching?

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take?

A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?