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

Valsartan is an angiotensin II receptor blocker that lowers blood pressure by blocking the vasoconstrictive and aldosterone-secreting effects of angiotensin II. Loweringblood pressure reduces the workload of the heart and improves cardiac function in patients with heart failure . Decreased urinary output, increased heart rate, and increased potassium level are not expected outcomes of valsartan therapy and may indicate worsening of heart failure or adverse effects of the medication.

A. Increase the client's fluid intake. B. Check the client's urine output. C. Reposition the client in bed. D. Administer PRN pain medication.

Correct Answer is B

Explanation

Continuous bladder irrigation (CBI) is a procedure that involves instilling sterile fluid into the bladder through a three-way catheter to prevent clot formation and maintain patency after a TURP surgery. The nurse should monitor the client's urine output closely and report any signs of obstruction such as decreased urine flow, blood clots, or abdominal pain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an indication that the medication is effective?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take?

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?

A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching?

A nurse is reviewing the following ABG results for a postoperative client: pH 7.27, PaCO2 49 mm Hg, PaO2 65 mm Hg, HCO 22 mEq/L. The nurse should interpret the findings as which of the following imbalances?

A nurse is providing discharge teaching about foot care to a client who is newly diagnosed with type 1 diabetes mellitus. Which of the following information should the nurse include?

A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects?

A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have at the bedside?