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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Placing the client with the head reclined back can increase the risk of aspiration and is not recommended.
B. Placing food in the affected side of the mouth could lead to choking, as the client may have reduced sensation or control on that side.
C. Encouraging the client to take small bites can help prevent choking and make swallowing easier.
D. While exercise might promote appetite, it is not directly related to feeding safety and should be discussed separately from swallowing instructions.
Correct Answer is B
Explanation
A. Monitor level of consciousness (LOC): While monitoring the patient's level of consciousness is important, administering medication to stop the seizure takes precedence to prevent potential complications associated with prolonged seizure activity.
B. Administer lorazepam (Ativan) 4 mg IV: The priority in managing continuous tonic-clonic seizures is to terminate the seizure activity promptly. Lorazepam is a benzodiazepine that can help to abort seizures and is often used as first-line treatment in the acute setting.
C. Obtain computed tomography (CT) scan: While obtaining diagnostic imaging such as a CT scan may be necessary to evaluate for underlying causes of the seizure, it is not the first
intervention in the acute management of continuous seizures. Stabilizing the patient and stopping the seizure activity take precedence.
D. Give phenytoin (Dilantin) 100 mg IV: Phenytoin is an antiepileptic medication that is used for long-term management of seizures but is not typically administered as first-line treatment during an acute seizure episode. Benzodiazepines like lorazepam are preferred for immediate seizure control.
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