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: The black category in the START triage system is for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is not in that category since they are conscious and breathing.
Choice B reason: The green category is for clients who are ambulatory with minor injuries and do not require urgent medical attention. This client is experiencing significant respiratory distress, which categorizes them as more urgent.
Choice C reason: The red category is for clients who need immediate life-saving intervention. This client's respiratory rate of 36 and shortness of breath indicate a severe respiratory distress that requires urgent medical attention.
Choice D reason: The yellow category is for clients who are unable to walk but have stable conditions that do not require immediate life-saving intervention. This client's condition is more severe and needs prompt intervention.
Correct Answer is B
Explanation
Choice A reason: Providing a centralized area for stocking the needed supplies is important for logistical reasons, ensuring that all necessary materials are readily available. However, this is not the primary scientific rationale for designating a specific decontamination area. The primary focus is on preventing contamination and ensuring safety.
Choice B reason: Preventing secondary contamination to health-care providers is the most crucial reason for designating a specific area for decontamination. This measure is vital to avoid spreading hazardous substances to others and ensuring the safety and effectiveness of the decontamination process. By containing the contamination in a controlled area, health-care providers can minimize the risk of exposure and cross-contamination.
Choice C reason: Designating an area where bioterrorism clients can receive care is important, but it is not the primary rationale for having a specific decontamination area. While care and treatment are critical, the main goal of the decontamination area is to remove contaminants and protect health-care providers and other patients from exposure.
Choice D reason: Providing showers and privacy to the client in the decontamination area is beneficial for the comfort and dignity of the client. However, this is not the main scientific rationale for having a designated decontamination area. The primary reason is to control and contain contamination and prevent it from spreading.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.