The nurse has just received a change-of-shift report on the following four clients. Which client should the nurse see first?
a) A 30-year-old client with a subarachnoid hemorrhage 4 days ago who has nimodipine (Nimotop) scheduled.
b) A 60-year-old client with right-sided weakness who received an infusion of tPA 8 hours ago.
c) A 50-year-old client who has chronic atrial fibrillation and a dose of warfarin (Coumadin) due.
d) A 40-year-old client who experienced a transient ischemic attack yesterday who has a dose of aspirin due.
The correct answer is: b) A 60-year-old client with right-sided weakness who received an infusion of tPA 8 hours ago.
Choice A reason: While the client with a subarachnoid hemorrhage needs close monitoring, the administration of nimodipine is essential but not immediately life-threatening compared to the post-tPA monitoring requirements.
Choice B reason: This client received tissue plasminogen activator (tPA) 8 hours ago, which is critical for treating ischemic stroke. They are at a high risk of complications such as bleeding and must be monitored closely for any signs of adverse effects, making them the priority.
Choice C reason: The client with chronic atrial fibrillation due for warfarin can be attended to after addressing more urgent needs. Chronic atrial fibrillation management is important, but it is less urgent than post-tPA care.
Choice D reason: The client who experienced a transient ischemic attack and is due for aspirin is stable compared to the client who recently received tP
A 30-year-old client with a subarachnoid hemorrhage 4 days ago who has nimodipine (Nimotop) scheduled.
A 60-year-old client with right-sided weakness who received an infusion of tPA 8 hours ago.
A 50-year-old client who has chronic atrial fibrillation and a dose of warfarin (Coumadin) due.
A 40-year-old client who experienced a transient ischemic attack yesterday who has a dose of aspirin due.
The Correct Answer is B
Choice A reason: While the client with a subarachnoid hemorrhage needs close monitoring, the administration of nimodipine is essential but not immediately life-threatening compared to the post-tPA monitoring requirements.
Choice B reason: This client received tissue plasminogen activator (tPA) 8 hours ago, which is critical for treating ischemic stroke. They are at a high risk of complications such as bleeding and must be monitored closely for any signs of adverse effects, making them the priority.
Choice C reason: The client with chronic atrial fibrillation due for warfarin can be attended to after addressing more urgent needs. Chronic atrial fibrillation management is important, but it is less urgent than post-tPA care.
Choice D reason: The client who experienced a transient ischemic attack and is due for aspirin is stable compared to the client who recently received tPA. While aspirin is important for preventing further strokes, it does not require the same level of immediate monitoring as the post-tPA client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Calling the provider is important, but it is not the immediate priority. Before contacting the provider, the nurse needs to assess the client's condition to provide accurate information about any potential adverse effects of the medication error.
Choice B reason: Notifying risk management is a necessary step in reporting the medication error, but it should be done after ensuring the client's safety and stability. Immediate patient assessment takes precedence.
Choice C reason: Checking the client's vital signs is the priority action because it allows the nurse to assess the client's current condition and identify any immediate adverse effects of the medication error. This information is critical for determining the appropriate next steps and ensuring the client's safety.
Choice D reason: Completing an incident report is essential for documenting the medication error, but it should be done after addressing the client's immediate needs and ensuring their safety. The nurse's first responsibility is to assess and manage the client's condition.
Correct Answer is B
Explanation
Choice A reason: Reassessing the client when the provider arrives to obtain the informed consent may be necessary, but it is not the priority action. The nurse needs to ensure that the provider is aware of the client's current mental status before any attempt to obtain informed consent is made.
Choice B reason: Notifying the provider of the client's orientation is the priority action. The client's intermittent confusion indicates that she may not have the capacity to provide informed consent. The provider needs to be aware of this to take appropriate steps, such as involving a legal representative or family member, to obtain consent.
Choice C reason: Calling the nursing supervisor to give consent for the surgery is not appropriate. The nursing supervisor does not have the legal authority to provide consent on behalf of the client.
Choice D reason: Asking another nurse to witness the informed consent does not address the issue of the client's mental status and ability to provide informed consent. This action is not appropriate given the client's intermittent confusion.
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