A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

Start a labetalol drip to keep BP less than 140/90 mm Hg.

Keep the head of the bed elevated at least 30 degrees.

Begin tissue plasminogen activator (tPA) intravenously per protocol.

Infuse normal saline intravenously at 75 mL/hr.

Answer and Explanation

The Correct Answer is C

A. Start a labetalol drip to keep BP less than 140/90 mm Hg: This order is appropriate because it aims to lower the patient's blood pressure to a target range recommended for acute ischemic stroke management.

B. Keep the head of the bed elevated at least 30 degrees: This intervention is part of stroke management to prevent aspiration and improve cerebral perfusion.

C. Begin tissue plasminogen activator (tPA) intravenously per protocol: The nurse should question this order because tissue plasminogen activator (tPA) is contraindicated in patients with stroke who have had symptoms for more than 3 hours or have unknown time of onset, as in this case where the patient has been aphasic for 3 hours. Administering tPA in this situation could increase the risk of bleeding complications without providing benefit.

D. Infuse normal saline intravenously at 75 mL/hr: This order is appropriate for maintaining hydration and intravascular volume in the acute care setting.

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Correct Answer is B

Explanation

A. Restrain the patient's arms and legs to prevent injury during the seizure: Restraint during a seizure can potentially cause harm to the patient and should be avoided. It is essential to ensure the patient's safety by protecting the head and providing a safe environment.

B. Time and observe and record the details of the seizure and postictal state: Timing the seizure, observing the type and duration of movements, and noting any changes in the patient's behavior during the postictal state are crucial for documenting the seizure accurately and guiding further management.

C. Insert an oral airway during the seizure to maintain a patent airway: Inserting an oral airway during an active seizure is not recommended and can increase the risk of injury to the patient's airway. Maintaining a clear airway is important, but interventions such as positioning and
suctioning may be sufficient without the need for airway adjuncts during the seizure.

D. Avoid touching the patient to prevent further nervous system stimulation: While it's essential to minimize stimulation during a seizure, avoiding touching the patient altogether may not be feasible or necessary for providing care. Ensuring a safe environment and providing appropriate support are priorities during a seizure.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The nurse and address the clients right shoulder pain after addressing the clients drowsiness. a clients recovery can be affected by pain by inhibiting their ability to become active and involved in self-care. The goal is to provide pain relief so that the client is able to participate in the recovery and to improve the clients functional status. Assessment of paint should include intensity, quality, duration, and location.

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A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

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Naxlex Comprehensive Predictor Exams

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a 24-year-old client who reports a recent fall, hitting their head and right shoulder. Exhibits Complete the following sentence by using the list of options. The nurse should first address the client's dropdown followed by the client's dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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