A nurse in an emergency department is caring for a client who is to receive tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. In which order should the nurse complete the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Weigh the client.

Check for contraindications.

Administer the tPA.

Transfer the client to the CCU.

Answer and Explanation

The Correct Answer is B,A,C,D

The nurse should first check for contraindications to tPA, such as hemorrhagic stroke, recent surgery, bleeding disorder, or uncontrolled hypertension. Then, the nurse should weigh the client to calculate the correct dose of tPA based on body weight. Next, the nurse should administer the tPA within three hours of symptom onset to improve the chances of recovery. Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and possible complications.

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Correct Answer is D

Explanation

The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.

A. Neck-vein distention B. Ankle edema C. Anorexia D. Hacking cough

Correct Answer is D

Explanation

A hacking cough, especially at night or when lying down, is a common manifestation of left-sided heart failure, as fluid accumulates in the lungs and causes pulmonary congestion and dyspnea. Neck-vein distention and ankle edema are more indicative of right-sided heart failure, as fluid backs up into the systemic circulation and causes peripheral edema and jugular venous pressure elevation. Anorexia may occur in either type of heart failure, but it is not specific to left-sided heart failure.

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Naxlex Comprehensive Predictor Exams

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has left-sided heart failure. Which of the following manifestations should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is checking a client's ventilator settings. The nurse should understand that positive end- expiratory pressure has which of the following purposes?

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take?

A nurse in the emergency department admitted a client who is having a myocardial infarction. The client has been placed on the heart monitor. Which of the following electrocardiogram strips is indicative of a myocardial infarction?

A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

A nurse is completing discharge teaching with a client who has a peripherally inserted central catheter (PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching?

A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?