A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?

Current anticoagulant use

Blood pressure of 160/85 mm Hg

Complete neurologic assessment

Current treatment for client's peptic ulcer disease

Answer and Explanation

The Correct Answer is A

A. Current anticoagulant use is crucial to assess before administering t-PA because combining t-PA with anticoagulants can significantly increase the risk of bleeding complications. It is essential to ensure that the client is not on medications that could interact adversely with t-PA.
B. While blood pressure is important to monitor, it is secondary to assessing anticoagulant use since high blood pressure alone does not contraindicate t-PA administration.
C. A complete neurologic assessment is important for determining the extent of the stroke but is not the immediate priority before administering t-PA.
D. While treatment for peptic ulcer disease is relevant, it is not directly related to the immediate risk factors for t-PA administration compared to anticoagulant use.

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Correct Answer is C

Explanation

C. The unconscious adult client with a sucking chest wound and low SpO2 (85%) is in immediate need of intervention. A sucking chest wound is a life-threatening injury that can lead to respiratory distress and compromised oxygenation. This client requires immediate attention to address the chest wound and improve oxygenation.
A. The unconscious client with no respirations and an ineffective airway attempt is likely beyond rescue, making them lower priority compared to those with potentially reversible conditions.
B. The conscious client with a broken tibia and elevated vital signs is stable enough to be seen after more critical cases are addressed.
D. The conscious client with shortness of breath and a high respiratory rate is concerning but not as immediately life-threatening as a client with a sucking chest wound.

A. Place the client on protective isolation. B. Initiate measures to prevent venous thromboembolism. C. Initiate droplet precautions. D. Check the client's most recent platelet level.

Correct Answer is D

Explanation

A. Protective isolation is not directly related to the symptoms of ecchymoses and petechiae but is more relevant for preventing infections in immunocompromised clients.
B. Measures to prevent venous thromboembolism are not the immediate concern given the bleeding symptoms; instead, managing platelet levels and bleeding risks is more critical.
C. Droplet precautions are not indicated based on the described symptoms, which are more related to bleeding disorders rather than infectious conditions requiring droplet precautions.
D. Checking the client's most recent platelet level is the most appropriate action because ecchymoses and petechiae are signs of potential thrombocytopenia (low platelet count), which is common in leukemia. Monitoring platelet levels will help determine if there is a need for interventions to address bleeding risks.

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A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is the triage officer in the emergency department during a disaster when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

Correct Answer is C

Explanation

A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. Based on the most recent assessment findings, the nurse should perform which action?

Correct Answer is D

Explanation

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