A patient comes into the emergency department with symptoms of a stroke that began 2 hours ago. Diagnostic testing confirms an ischemic stroke is present. What medications should the nurse anticipate will be delivered?

Heparin

Tissue-type plasminogen activator (tPA)

Warfarin

Clopidogrel

Answer and Explanation

The Correct Answer is B

A. Heparin: Heparin is an anticoagulant, but it is not typically used in the acute management of ischemic stroke because it does not dissolve clots already formed. It may be used later for prophylaxis against new clots.
B. Tissue-type plasminogen activator (tPA): This is correct. tPA is a thrombolytic agent that can dissolve the clot causing the stroke. It is most effective when given within a few hours of symptom onset, making it the appropriate medication in this scenario.
C. Warfarin: Warfarin is an oral anticoagulant used for long-term prevention of clot formation but is not suitable for immediate thrombolytic therapy in acute ischemic stroke.
D. Clopidogrel: Clopidogrel is an antiplatelet medication used for secondary prevention of strokes but is not used for acute thrombolysis.

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Correct Answer is D

Explanation

A. Lying prone as prescribed: While lying prone can help prevent hip flexion contractures, it is not directly related to promoting ambulation. It is typically part of post-operative care to prevent contractures in the hip, but ambulation primarily depends on upper body strength and prosthetic training.
B. Maintaining residual limb elevation: Elevation of the residual limb is important immediately postoperatively to reduce swelling, but prolonged elevation can lead to contractures, which can hinder ambulation.
C. Promoting coordination exercises: Coordination is important, but for ambulation, building strength, especially in the upper body, is crucial to support the use of assistive devices and maintaining balance.
D. Building upper body strength: This is essential for promoting ambulation as it helps the patient in using assistive devices like crutches or walkers and in transferring safely. Upper body strength is crucial for balance and mobility with a prosthetic limb.

A. Obtain an electrocardiogram (ECG) exam B. Obtain intravenous access C. Administer 2 L of oxygen per nasal cannula D. Obtain a rectal temperature

Correct Answer is C

Explanation

A. Obtain an electrocardiogram (ECG) exam: While an ECG is important to assess cardiac status, it is not the immediate priority compared to addressing the low oxygen saturation.
B. Obtain intravenous access: IV access is important for administering medications and fluids but does not take precedence over addressing hypoxia.
C. Administer 2 L of oxygen per nasal cannula: This is correct. The priority is to improve oxygenation since hypoxia can exacerbate neurological damage in a stroke patient. An SpO2 of 88% is low and requires immediate correction to prevent further complications.
D. Obtain a rectal temperature: Temperature assessment is not as urgent as addressing the immediate need for oxygen to improve SpO2 levels.

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A patient comes into the emergency department with symptoms of a stroke that began 2 hours ago. Diagnostic testing confirms an ischemic stroke is present. What medications should the nurse anticipate will be delivered?

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Naxlex Comprehensive Predictor Exams

The nurse is providing care for a patient after an above-the-knee amputation because of diabetes complications. Which nursing care is essential for promoting ambulation?

Correct Answer is D

Explanation

The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Correct Answer is C

Explanation

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