A nurse in an emergency department is caring for a client who has manifestations of an ischemic stroke that began 2 hr ago. Which of the following actions should the nurse take?

Initiate fibrinolytic therapy.

Place the client in a supine position.

Prepare the client for a chest x-ray.

Insert an indwelling urinary catheter.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Initiate fibrinolytic therapy: Fibrinolytic therapy, such as tissue plasminogen activator (tPA), is most effective when administered within a 3- to 4.5-hour window from the onset of ischemic stroke symptoms. Early administration can dissolve the clot, restore cerebral blood flow, and improve neurological outcomes.

B. Place the client in a supine position: Clients with ischemic stroke are usually positioned with the head of the bed elevated 15–30 degrees unless contraindicated. Supine positioning can increase intracranial pressure and risk aspiration, which may worsen neurological status.

C. Prepare the client for a chest x-ray: A chest x-ray is not a priority in acute ischemic stroke management. Immediate neuroimaging, typically a CT scan, is required to differentiate ischemic from hemorrhagic stroke before initiating fibrinolytic therapy.

D. Insert an indwelling urinary catheter: Inserting a catheter is not indicated as an initial intervention for acute stroke unless the client is unable to void or requires strict output monitoring. Priority actions focus on neuroprotection and reperfusion therapy.

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Correct Answer is ["C","D"]

Explanation

Rationale for Correct Choices

• Intravenous antibiotic: The client shows classic signs of postpartum endometritis, including fever, uterine tenderness, boggy fundus, and foul-smelling lochia. IV antibiotics are the primary treatment to target the uterine infection and prevent progression or sepsis.

• Increase in daily fluid intake: Adequate hydration supports circulation, helps maintain uterine tone, and assists in reducing the risk of complications such as hypotension or dehydration from infection. Fluids also support antibiotic therapy by promoting renal clearance and overall recovery.

Rationale for Incorrect Choices

• Kleihauer-Betke test: This test identifies fetal-to-maternal hemorrhage, which is not indicated here because the client’s hemoglobin is stable and there is no evidence of significant postpartum hemorrhage.

• Tocolytic medication: Tocolytics are used to suppress preterm labor, which is irrelevant for this postpartum client whose uterus has already delivered the fetus.

• Intrauterine tamponade balloon: This intervention is used for severe postpartum hemorrhage to mechanically control bleeding. The client’s bleeding is moderate and the uterus is firm after massage, so this is not indicated at this time.

A. Skin warm and dry B. Respiratory rate 30/min C. Heart rate 60/min D. Tenting skin turgor

Correct Answer is B

Explanation

Rationale:
A. Skin warm and dry: Warm, dry skin indicates adequate circulation and fluid balance. In fluid overload, the skin is often cool and moist due to peripheral vasodilation and increased interstitial fluid. Therefore, this finding is not consistent with overhydration.

B. Respiratory rate 30/min: Tachypnea is a key indicator of fluid overload because excess fluid can accumulate in the lungs, leading to pulmonary congestion and decreased gas exchange. The body compensates by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide.

C. Heart rate 60/min: A normal heart rate suggests stable cardiovascular status. Fluid overload typically causes tachycardia as the heart works harder to manage increased circulatory volume, not a normal or bradycardic rate.

D. Tenting skin turgor: Tenting indicates dehydration, not fluid overload. In overhydration, the skin is usually taut and edematous due to excess interstitial fluid accumulation rather than loss of elasticity.

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A nurse in an emergency department is caring for a client who has manifestations of an ischemic stroke that began 2 hr ago. Which of the following actions should the nurse take?

Nursing Test Bank

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