A client with new onset right-sided weakness is admitted to the emergency department and the following orders are received. Which order should the nurse implement first?

Aspirin 325mg po

Non-contrast computed tomography (CT) scan

Electrocardiogram (ECG)

Simvastatin (Zocor) 80 mg po

Answer and Explanation

The Correct Answer is B

A. Aspirin 325 mg PO: Aspirin is important for preventing clot formation but should not be administered until a hemorrhagic stroke is ruled out.

B. Non-contrast computed tomography (CT) scan: This is the priority because it determines whether the stroke is ischemic or hemorrhagic, guiding further treatment.

C. Electrocardiogram (ECG): While assessing cardiac rhythm is important, it is not the immediate priority in the presence of stroke symptoms.

D. Simvastatin (Zocor) 80 mg PO: Statins are used for long-term management but are not urgent in this acute scenario.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Hold the medication and notify the HCP: This is unnecessary. An INR of 2.7 is within the therapeutic range for a client with a mechanical valve replacement (2.5 to 3.5). No intervention is required.

B. Administer the medication as ordered: The INR of 2.7 is within the desired therapeutic range for clients on warfarin with mechanical valve replacements, so the nurse should proceed with the prescribed dose.

C. Prepare to administer vitamin K (AquaMephyton): Vitamin K is used to reverse the effects of warfarin if the INR is too high (usually greater than 5).

D. Assess the client for abnormal bleeding: While important, this is not the first action. The INR is within the therapeutic range, so the priority is to administer the medication.

A. To increase hydration B. To control symptoms C. To promote nutrition D. To limit environmental hazards

Correct Answer is B

Explanation

A. To increase hydration: This is not a priority in terminal care. In fact, increasing hydration can be uncomfortable for dying patients who are often unable to process fluids effectively.

B. To control symptoms: The primary focus in end-of-life care is to manage symptoms, such as pain, difficulty breathing, and anxiety, to ensure the patient is as comfortable as possible.

C. To promote nutrition: At the end of life, promoting nutrition is usually not the priority, as the client may no longer desire food and may be unable to tolerate it.

D. To limit environmental hazards: While important, it is not the priority in terminal care. The focus should be on comfort and symptom control.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client with new onset right-sided weakness is admitted to the emergency department and the following orders are received. Which order should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse is caring for a client who is terminally and approaching the end of life. Which goal would the nurse identify as the priority?

Correct Answer is B

Explanation

The nurse is teaching a class to a group of staff nurses about traumatic brain injury which condition would the nurse identify as having the highest risk of a fatal outcome within the first 24 hours post-injury?

The nurse obtains a health history from a patient with a prosthetic mitral value. Which question by the nurse would help to identify a risk factor for infectious endocarditis

The nurse is educating a client diagnosed with mitral valve prolapse. What education will the nurse need to provide the client about this diagnosis? Possible Education

A client with new-onset atrial flutter is unresponsive to drug therapy and is scheduled to receive further treatment. Which intervention should the nurse prepare the client to receive?

The nurse is assessing a client who is near death. Which of the following findings would indicate to the nurse that the client is in the actively dying phase?

The nurse is caring for a client who has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which type of intravenous solution would the nurse expect to administer to the client?

The nurse is documenting a client’s assessment. The rhythm below was obtained from the client’s cardiac monitor. How should the nurse document this strip?