Patient Data

Exhibits

The client is ready for transfer to the neurological intensive care unit (ICU). The receiving nurse obtains report from the emergency department (ED) nurse.

Received a computed tomography (CT) scan of the head 18 gauge peripheral IV (PIV) in bilateral antecubital spaces

CMP, WBC, APTT, PT/INR drawn and results are all WNL

12-Lead ECG normal sinus rhythm (NSR)

0.9% sodium chloride infusing at 50mL/hour

Sitting in a semi Fowler's position

Client is NPO

Pharmacy bringing tissue plasminogen activator (tPA) to the unit shortly

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

During tPA administration, the nurse should prioritize
dropdown
to monitor for
dropdown
.

Answer and Explanation

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

Rationale for Correct Choices:

Frequent neurologic assessments: Frequent neurological checks are crucial during and after tPA administration to detect early signs of complications, particularly worsening neurological status, which may indicate intracranial bleeding. These assessments help ensure prompt intervention if deterioration occurs.
Intracerebral hemorrhage: Intracerebral hemorrhage is the most serious and well-known risk of thrombolytic therapy. Monitoring for signs such as sudden headache, changes in consciousness, or worsening neurological symptoms is essential to detect this life-threatening complication early.

Rationale for Incorrect Choices:

Continuous blood pressure monitoring: Although blood pressure control is important during tPA administration, continuous monitoring is not always required. Frequent checks (e.g., every 15 minutes) are typically sufficient unless there is an acute hypertensive crisis or rapid changes in neurological status.
Hourly intake and output measuring: While intake and output may be monitored in ICU settings, this is not the priority during tPA administration. It does not help in detecting the most immediate and severe risk associated with thrombolytics.
Pulmonary embolism: tPA is used to treat embolic events, not likely to cause them. Pulmonary embolism is not a known complication of thrombolytic therapy in ischemic stroke cases and would not be the primary concern during administration.
Deep vein thrombosis: DVT is a potential complication from immobility in stroke patients, but not from tPA use. Monitoring for DVT is important during hospitalization but is not the priority during or immediately after tPA infusion.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. The client's need for pain medication should be determined: Ensuring comfort is the top priority in end-of-life care, especially for a client with a DNR order. Assessing and managing pain helps uphold dignity and minimize suffering during the dying process.

B. The impending signs of death should be documented: Documentation is essential for maintaining accurate medical records, but it is not the first priority. Ensuring the client is comfortable and free from pain takes precedence over recording observations.

C. The client's status should be conveyed to the chaplain: Spiritual support is important, but it should follow after the client’s physical needs—especially pain relief—are addressed. Involving the chaplain is helpful but not the most urgent intervention in this context.

D. The nurse manager should be updated on the client's status: Informing leadership may be necessary for planning purposes, but it does not directly benefit the client’s care in the moment. Addressing physical symptoms must come before administrative communication.

A. Any antianxiety medications. B. Over-the-counter oral antipyretics. C. Nonsteroidal antiinflammatory drugs. D. Other beta-adrenergic blocker agents. E. Oral and subcutaneous anticoagulants.

Correct Answer is ["C","D"]

Explanation

Rationale:
A. Any antianxiety medications: Antianxiety medications are not contraindicated with ophthalmic timolol. Unless they directly impact heart rate or blood pressure significantly, they are generally safe to continue in clients with glaucoma using topical beta blockers.

B. Over-the-counter oral antipyretics: Oral antipyretics like acetaminophen are not known to interact adversely with timolol. These medications can be used safely unless otherwise contraindicated for specific patient conditions like liver disease.

C. Nonsteroidal antiinflammatory drugs: NSAIDs such as ibuprofen, when used long-term with beta blockers like timolol or carvedilol, may blunt the antihypertensive effect and increase renal risk, especially in clients on diuretics like spironolactone. This triple combination increases the chance of nephrotoxicity.

D. Other beta-adrenergic blocker agents: Using timolol with systemic beta blockers like carvedilol increases the risk of bradycardia, hypotension, and heart block. Though timolol is topical, systemic absorption can still occur, requiring caution when combining with other beta-blockers.

E. Oral and subcutaneous anticoagulants: There is no direct contraindication between timolol and anticoagulants. Unless the client has bleeding risks associated with other therapies or conditions, concurrent use is generally acceptable.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, which priority action should the nurse implement?

Correct Answer is A

Explanation

The nurse administers ophthalmic timolol to a client with glaucoma. The client routinely takes carvedilol, spironolactone, and ibuprofen daily. Which medication(s) should the nurse withhold? Select all that apply.

Correct Answer is ["C","D"]

Explanation

When providing education for a client newly diagnosed with type 1diabetes, which information is most important for the nurse to provide the client?

A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

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The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?

During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first?

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse delegate to the UAP?

Exhibits The nurse reviews the clinical findings. For each of the findings listed, click to indicate which are consistent with the disease process of major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder. Each column must have at least one response selected.