A client presents to the emergency department with a sudden onset of left-sided weakness, difficulty speaking, and a facial droop on the left side.
Which action should the nurse prioritize?

Obtain a CT scan of the brain without contrast.

Obtain a CT scan with contrast.

Administer a thrombolytic agent.

Begin intravenous hydration.

Answer and Explanation

The Correct Answer is A

Acute stroke management requires rapid application of the time-is-brain principle. Knowledge of the differential diagnosis between ischemic and hemorrhagic strokes is vital. Practitioners must prioritize diagnostic imaging that safely identifies hemorrhage to determine if thrombolytic therapy is indicated.

Choice A rationale

A non-contrast CT scan is the gold standard for initial stroke assessment to rule out intracranial hemorrhage. It is faster than an MRI and avoids contrast, which can mimic blood or cause kidney injury in emergencies.

Choice B rationale

Contrast is avoided during the initial emergency scan because it can leak into brain tissue and appear hyperdense. This mimics the appearance of acute blood, making it difficult to distinguish between a bleed and ischemia.

Choice C rationale

Thrombolytics cannot be administered until a CT scan confirms the absence of a hemorrhage. Giving these drugs to a patient with a brain bleed would cause catastrophic worsening of the condition and potential death.

Choice D rationale

While IV access and hydration are important, they are secondary to identifying the type of stroke. Diagnostic imaging must occur first to facilitate the most time-sensitive treatments like fibrinolysis or mechanical thrombectomy for ischemia.

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Correct Answer is ["A","C","F","G","H"]

Explanation

Evaluating post surgical and post pulmonary embolism recovery requires assessing functional mobility, respiratory stability, and wound healing. Knowledge of normal rehabilitation milestones and the resolution of thromboembolic symptoms is necessary to determine if the client is meeting expected outcomes.

Choice A rationale

Independent performance of activities of daily living indicates restored functional capacity and successful rehabilitation after surgery. It demonstrates that the client has regained sufficient strength and coordination to manage self care tasks without exhausting their cardiovascular reserves.

Choice B rationale

Unintentional weight loss of 27 lbs within six weeks is an abnormal finding that suggests underlying pathology, malnutrition, or chronic illness. It does not indicate improvement and instead necessitates further medical investigation to rule out complications.

Choice C rationale

Transitioning to independent walking with a cane shows progress in gait stability and weight bearing tolerance on the prosthetic joint. This movement away from more restrictive assistive devices like walkers is a positive indicator of recovery.

Choice D rationale

Significant bruising and discoloration are concerning signs, potentially indicating a bleeding disorder or complications from ongoing anticoagulation therapy. This finding represents a setback or a new problem rather than a sign of successful clinical improvement.

Choice E rationale

Increased pain with movement in the surgical area suggests potential complications such as infection, prosthesis loosening, or hip dislocation. Expected progress involves a steady decrease in pain levels as the surgical site heals over the weeks.

Choice F rationale

The absence of shortness of breath and chest pain indicates that the pulmonary embolism has resolved and gas exchange is stable. This respiratory comfort suggests that pulmonary perfusion has been restored and the lungs are healing.

Choice G rationale

An oxygen saturation of 95 is within the normal range of 95 to 100 percent. This indicates adequate arterial oxygenation and demonstrates that the client no longer requires supplemental oxygen to maintain systemic tissue perfusion after recovery.

Choice H rationale

A visible hairline scar without redness, swelling, or drainage confirms successful primary intention healing of the surgical incision. This indicates that the skin integrity is restored and the risk of localized or systemic infection is decreasing.

A. Intermittent bubbling in the water seal chamber. B. Mild crepitus at the insertion site. C. Drainage of 75 mL serosanguineous fluid in 1 hour. D. Tracheal deviation away from the affected side.

Correct Answer is D

Explanation

Chest tube management requires distinguishing between expected findings and signs of tension pneumothorax. Knowledge of thoracic pressure dynamics and complications is essential. Immediate action is required when anatomical shifts indicate a significant increase in pleural pressure and compromised cardiac output.

Choice A rationale

Intermittent bubbling in the water seal chamber is a normal finding in a client with a pneumothorax. It indicates that air is being evacuated from the pleural space during expiration or coughing and does not require immediate reporting.

Choice B rationale

Mild crepitus, or subcutaneous emphysema, is common near the insertion site as small amounts of air leak into the tissues. While it should be monitored for progression, it is not as urgent as signs of mediastinal shift.

Choice C rationale

Drainage of 75 mL per hour of serosanguineous fluid is generally considered within the acceptable range post thoracotomy. Reporting is typically required if drainage exceeds 100 mL per hour or if the color changes to bright red.

Choice D rationale

This is a classic sign of a tension pneumothorax, a medical emergency. Rapid air accumulation increases intrapleural pressure, pushing the mediastinum and trachea toward the unaffected side, which can lead to rapid obstructive shock and death.

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A client presents to the emergency department with a sudden onset of left-sided weakness, difficulty speaking, and a facial droop on the left side. Which action should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","F","G","H"]

Explanation

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. Which finding requires immediate reporting?

Correct Answer is D

Explanation

The nurse prepares a continuous aminophylline infusion at 0.3 mg/kg/hr for a client weighing 165 pounds. The bag is mixed with 500 mg of aminophylline in 250 mL of D5W. At which rate should the nurse set the pump in mL/hr? Round the answer to the tenths place.

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A client presents to the emergency department with a sudden onset of left-sided weakness, difficulty speaking, and a facial droop on the left side.
Which action should the nurse prioritize?