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Patient Data

Exhibits

The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.
What interdisciplinary team member(s) should assist the client in recovery? Select all that apply.

Case Manager

Occupational Therapist

Speech Therapist

Respiratory Therapist

Chief Nursing Officer

Medical Assistant

Pharmacy Technician

Physical Therapist

Answer and Explanation

Correct Answer : A,B,C,H

A.   A case manager can coordinate the overall care plan, ensuring the client receives appropriate services and support during recovery and discharge planning.
B.   An occupational therapist can help the client regain the ability to perform activities of daily living (ADLs) and improve fine motor skills affected by the stroke.
C.   A speech therapist can assist the client with speech and language difficulties, as well as swallowing issues that may have resulted from the stroke.
D.   A respiratory therapist is typically involved if there are respiratory issues, which are not indicated in this case.
E.   A chief nursing officer provides leadership and oversight roles, and not direct patient care.
F.   A medical assistant is typically involved in basic clinical tasks but not in specialized stroke recovery.
G.   A pharmacy technician fills prescriptions but doesn’t directly participate in client rehabilitation.
H.   A physical therapist can help the client improve strength, balance, and mobility, which are often impaired after a

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Elevating the head of the bed can help improve oxygenation but is not directly related to managing sepsis.
B. Monitoring blood glucose levels is crucial in sepsis management as hyperglycemia can exacerbate the inflammatory response.
C. While intake and output monitoring is important, it is not the priority in the early management of sepsis.
D. Assessing warmth of extremities is important but not the most critical intervention in managing sepsis.

A. Monitor the amount of drainage from the client's incision. B. Observe both lower extremities for redness and swelling. C. Evaluate the client's ability to use an incentive spirometer. D. Palpate all peripheral pulse points for volume and strength.

Correct Answer is B

Explanation

A. Monitoring incision drainage is important for infection and wound healing but not directly related to the effectiveness of compression devices.
B. Observing both lower extremities for redness and swelling directly assesses the effectiveness of the pneumatic compression devices in preventing deep vein thrombosis (DVT).
C. Evaluating the use of an incentive spirometer is important for respiratory function but unrelated to the compression devices.
D. Palpating peripheral pulse points is useful for circulation assessment but does not specifically evaluate the prevention of DVT, which is the primary purpose of the compression devices.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is B

Explanation

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is B

Explanation

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