Based on the information in the electronic health record, complete the sentences using the drop-down lists.
The nurse's initial action after assessing the patient at 1600 is to
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Rationale for Correct Answers:
- Notify the provider: The client’s sudden change in level of consciousness, restlessness, irritability, and new headache after receiving alteplase indicates a potentially serious complication. Immediate notification of the healthcare provider is critical to ensure prompt evaluation, possible imaging, and interventions to prevent further neurological deterioration.
- Increased intracranial pressure: The new neurological symptoms, decreased responsiveness, irritability, and headache, suggest rising intracranial pressure (ICP), likely secondary to cerebral edema following ischemic stroke and thrombolytic therapy. Increased ICP can compromise cerebral perfusion and oxygenation, leading to rapid neurological decline. Early recognition and intervention are essential to prevent permanent damage or herniation.
Rationale for Incorrect Answers:
- Encourage the client to rest quietly: This delays emergency intervention. The symptoms indicate possible intracranial bleeding, not simple fatigue.
- Document the findings and continue routine monitoring: Routine monitoring is inappropriate when there is a sudden neurologic change after thrombolytic therapy. This is not stable, it is a potential life-threatening complication.
- Hypoglycemia: This can cause altered LOC, but there is no evidence in the scenario suggesting low blood glucose. Additionally, the new severe headache strongly suggests increased ICP.
- Anxiety: This does not cause decreased level of consciousness or focal neurologic decline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Calculation:
- Convert patient weight from pounds to kilograms
Weight = 158 ÷ 2.2
= 71.818 kg
- Determine norepinephrine concentration in mcg/mL
4 mg in 250 mL = 4000 mcg ÷ 250 Ml
= 16 mcg/mL
- Calculate the infusion rate in mL/min
Infusion rate = 18 mL/hr = 18 ÷ 60
= 0.3 mL/min
- Calculate norepinephrine dose in mcg/min
Dose in mcg/min = 0.3 × 16
= 4.8 mcg/min
- Calculate dose in mcg/kg/min
Dose = 4.8 ÷ 71.818
= 0.0669 mcg/kg/min
- Round to thousandths
= 0.067 mcg/kg/min
Correct Answer is A
Explanation
A. Serum potassium 6.5 mEq/L: Hyperkalemia is a life-threatening electrolyte imbalance commonly seen in burn patients due to cellular destruction and release of intracellular potassium. A potassium level of 6.5 mEq/L can precipitate dangerous cardiac dysrhythmias, including ventricular fibrillation or asystole. Immediate nursing interventions include cardiac monitoring, notifying the healthcare provider, and preparing for treatments.
B. Hematocrit 52%: Elevated hematocrit reflects hemoconcentration, which is common in burn patients due to fluid shifts and plasma loss. While it indicates dehydration and ongoing fluid resuscitation needs, it is not immediately life-threatening and can be addressed with continued monitoring and IV fluids.
C. Serum sodium 146 mEq/L: A sodium level slightly above normal indicates mild hypernatremia, which can occur due to fluid shifts and inadequate free water replacement. Although it requires monitoring and adjustment of fluid therapy, it does not pose the same immediate risk as hyperkalemia.
D. Urine specific gravity 1.005: This value suggests dilute urine, which may indicate adequate hydration or early renal impairment. While it warrants monitoring in the context of burn resuscitation, it does not require urgent intervention compared with a dangerously high potassium level.
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