A client in the emergency department is being prepared to receive tissue plasminogen activator (tPA). The nurse knows that which of the following is true regarding this medication?

The medication should be given with 5-6 hours of the onset of stroke systems

The medication is a primary treatment for haemorrhagic stroke.

The medication can be given to prevent clot formation in the context of head trauma

When given within a certain timeframe, the medication may dissolve an ischemic stroke

Answer and Explanation

The Correct Answer is D

A) "The medication should be given with 5-6 hours of the onset of stroke symptoms":
. tPA (tissue plasminogen activator) is typically given for an ischemic stroke, and it is most effective when administered within 3 to 4.5 hours of the onset of stroke symptoms. After this time frame, the risk of bleeding complications increases, and the benefits of the medication diminish significantly. Giving tPA after 6 hours is generally considered outside the therapeutic window for ischemic stroke, though some centers may extend the window based on specific criteria.

B) "The medication is a primary treatment for hemorrhagic stroke":
. tPA is contraindicated in hemorrhagic stroke because it works by dissolving clots, which could worsen bleeding in the brain. Hemorrhagic stroke occurs when there is bleeding in the brain, and administering tPA would exacerbate the bleeding, leading to more severe brain injury and complications. The primary treatment for hemorrhagic stroke is controlling bleeding, often through surgical interventions or managing blood pressure.

C) "The medication can be given to prevent clot formation in the context of head trauma":
. tPA is not used to prevent clot formation, particularly in the setting of head trauma. It is used to dissolve existing clots in cases of ischemic stroke. Administering tPA after head trauma or brain injury could lead to catastrophic complications, such as worsening bleeding, and should be avoided. The use of tPA is contraindicated in trauma-related situations unless the stroke is clearly ischemic and there are no signs of hemorrhage.

D) "When given within a certain timeframe, the medication may dissolve an ischemic stroke":
. tPA is the standard treatment for ischemic strokes (caused by a clot blocking blood flow to the brain). When administered within 3 to 4.5 hours of the onset of symptoms, tPA can dissolve the clot, improving blood flow to the affected area of the brain and potentially minimizing the damage caused by the stroke. Timely administration is critical for maximizing its benefits in reducing disability and improving outcomes.

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Correct Answer is A

Explanation

A) Wear a HEPA/N95 mask while providing care to the client:
Tuberculosis (TB) is a highly contagious airborne disease, and healthcare workers caring for patients with active TB must wear a HEPA/N95 mask to protect themselves from inhaling the bacteria. These specialized masks filter out airborne particles, including Mycobacterium tuberculosis, which can be spread through droplets when the patient coughs, sneezes, or talks. Wearing an N95 mask is an essential part of airborne precautions in the care of TB patients.

B) Instruct the nursing assistant to wear a surgical mask when entering the client's room:
A surgical mask does not offer adequate protection against airborne pathogens like the tuberculosis bacteria. While surgical masks can block large droplets, they do not filter out smaller, airborne particles, such as those from TB. N95/HEPA masks are necessary for anyone entering the room of a patient with active tuberculosis, including nursing assistants, to ensure they are protected from inhaling infectious particles.

C) Ensure the client is in a positive pressure room:
A positive pressure room is typically used for patients who are immunocompromised, such as those with neutropenia or undergoing organ transplants, to prevent infection from the environment. However, negative pressure rooms are required for patients with airborne diseases like tuberculosis. A negative pressure room ensures that air flows into the room but does not leave, containing any airborne pathogens and preventing their spread to other areas of the facility.

D) Have the client wear a HEPA/N95 mask when outside of their room:
If the client with active tuberculosis needs to leave their room for medical procedures or testing, they should wear a HEPA/N95 mask to prevent spreading the bacteria to others through airborne transmission. This helps limit exposure to other individuals, as TB can be transmitted by airborne particles.

A. "Be sure to bend at the hip, not the knee, to pick up items." B. internally rotating your leg is okay, but do not externally rotate it." C. If we need so help you roll in bed, we will roll you towards the operative side. D. You should keep your knees apart using a wedge or pillow.

Correct Answer is D

Explanation

A) "Be sure to bend at the hip, not the knee, to pick up items."
After hip replacement surgery, patients are instructed to avoid bending at the hip beyond 90 degrees, as this can dislocate the newly replaced hip. The correct guidance would be to avoid bending at the hip and instead bend at the knee when picking up items, ensuring the hip joint stays in a safe position.

B) "Internally rotating your leg is okay, but do not externally rotate it."
Internal rotation of the hip joint should also be avoided post-surgery, as it can increase the risk of dislocation. The correct teaching is to prevent both internal and external rotation of the hip to ensure the joint remains stable. Patients should be instructed to avoid twisting motions that can compromise the surgical repair.

C) "If we need to help you roll in bed, we will roll you towards the operative side."
This can place undue pressure on the newly replaced hip, potentially leading to dislocation or injury. The operative side should be kept stable and protected, so it is safer to roll the patient onto the non-operative side if necessary.

D) "You should keep your knees apart using a wedge or pillow."
It is essential to keep the knees apart, typically using a wedge or pillow between the legs. This prevents the hip from adducting (moving toward the midline) and reducing the risk of dislocation. Maintaining this position ensures the hip remains in a safe, stable alignment during the healing process.

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A client in the emergency department is being prepared to receive tissue plasminogen activator (tPA). The nurse knows that which of the following is true regarding this medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with active tuberculosis. Which of the following intervention are appropriate for this client?

Correct Answer is A

Explanation

Which of the following should be included in patient teaching after hip replacement surgery?

Correct Answer is D

Explanation

In which client would a prescription of valproic acid for seizure disorder be contraindicated?

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A client in the emergency department is being prepared to receive tissue plasminogen activator (tPA). The nurse knows that which of the following is true regarding this medication?

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