A 76-year-old woman arrives at the emergency department by ambulance with a possible stroke. Vital signs are pulse 90, blood pressure 150/100, respirations 20. Thirty minutes later, vital signs are pulse 78, blood pressure 170/90, respirations 24 and irregular. The nurse should take which action at this time?

Check the client's phenytoin (Dilantin) level.

Get an order to decrease the rate of IV fluids.

Ask the woman to describe how she's feeling.

Offer the client clear liquids to prevent dehydration.

Answer and Explanation

The Correct Answer is C

A. Check the client's phenytoin (Dilantin) level: Checking the phenytoin level would not be relevant in this situation as the client's presentation suggests a possible stroke, not related to phenytoin therapy.

B. Get an order to decrease the rate of IV fluids: While managing fluid balance is important, there is insufficient information to warrant decreasing IV fluids at this time. It's essential to assess the client's overall condition and consult with the healthcare provider before making changes to IV fluid administration.

C. Ask the woman to describe how she's feeling: Assessing the client's symptoms and response to treatment is crucial for monitoring her condition and guiding further interventions, especially in
the context of a possible stroke.

D. Offer the client clear liquids to prevent dehydration: While maintaining hydration is
important, offering clear liquids would not address the potential stroke or irregular respirations. Assessment and intervention related to the client's neurological status and respiratory function take precedence.

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Correct Answer is C

Explanation

A. Transfer the patient to radiology: Lumbar punctures are typically performed at the bedside in the patient's room or in a procedure room, not in radiology.
B. Enforce NPO status for 4 hours: NPO (nothing by mouth) status is not typically required before a lumbar puncture unless specifically ordered by the healthcare provider for a particular reason.
C. Help the patient to a lateral position: Before a lumbar puncture, the patient should be placed in a lateral recumbent position (usually on their side with knees flexed towards the chest) to facilitate the procedure and minimize the risk of complications such as post-dural puncture headache.
D. Administer a sedative medication: Sedative medications are not routinely administered before a lumbar puncture, as they can alter the patient's level of consciousness and interfere with neurological assessment during and after the procedure.

A. Oral Levetiracetam B. IV Lorazepam C. IV Ondansetron D. Magnesium Sulfate

Correct Answer is B

Explanation

A. Oral Levetiracetam: Oral medications are not appropriate for immediate seizure management during an active seizure. Intravenous medications are typically used for acute seizure management.

B. IV Lorazepam: Lorazepam is a benzodiazepine that is commonly used as a first-line medication for terminating acute seizures. It acts quickly to suppress seizure activity and is often administered intravenously during a seizure episode.

C. IV Ondansetron: Ondansetron is an antiemetic medication used to prevent nausea and vomiting and is not indicated for seizure management.

D. Magnesium Sulfate: Magnesium sulfate is not typically used for seizure management in the acute setting. It may be used for certain types of seizures or as a treatment for eclampsia, but it is not a first-line medication for acute seizure termination.

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Naxlex Comprehensive Predictor Exams

A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?

Correct Answer is C

Explanation

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following medication would the nurse anticipate to administer?

Correct Answer is B

Explanation

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

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