The nurse is caring for a client who arrives at the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. After obtaining vital signs, the nurse should implement which intervention?
Initiate bilateral intermittent sequential pneumatic compression devices.
Place an indwelling urinary catheter and measure strict intake and output.
Notify the stroke team to assist with acute assessment and management.
Administer aspirin to prevent further clot formation and platelet clumping.
The Correct Answer is C
Choice A reason: While pneumatic compression devices are used for DVT prevention, they are not the immediate intervention for suspected stroke.
Choice B reason: Placing an indwelling urinary catheter is not the first-line intervention for a patient with suspected stroke symptoms.
Choice C reason: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.
Choice D reason: Aspirin may be used in the management of stroke, but only after a stroke has been confirmed and not as an immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Before administering IV fluids containing potassium chloride, it is crucial to ensure that the client has adequate urinary output, typically between 30 to 60 mL/hr. This indicates good kidney function, which is necessary for the excretion of potassium to prevent hyperkalemia, a potentially life-threatening condition.
Choice B reason: While magnesium levels can affect potassium levels, they are not the most critical assessment before potassium infusion. However, it is important to monitor magnesium levels as part of the overall electrolyte balance, especially in diabetic ketoacidosis.
Choice C reason: The size of the IV catheter is important for administration purposes, but it is not the most critical assessment data before starting potassium infusion. The catheter size affects the flow rate and comfort during infusion but does not impact the decision to start the infusion.
Choice D reason: Serum glucose level is a vital parameter to monitor in diabetic ketoacidosis, but it is not the most critical assessment before starting potassium infusion. The primary concern with potassium infusion is kidney function, as assessed by urinary output.
Correct Answer is A
Explanation
Choice A reason: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.
Choice B reason: Palpating and comparing pedal pulse volumes is an important step to assess for vascular complications such as thrombosis or embolism. However, it is not the immediate priority when a client reports systemic symptoms like weakness and dizziness, which could be signs of more serious conditions.
Choice C reason: Measuring post-procedure intake and output is part of routine postoperative care to ensure proper fluid balance. While important, it is not the most critical action to take when a client is experiencing acute symptoms that could indicate life-threatening complications.
Choice D reason: Removing the dressing and observing the site might be indicated if there is suspicion of bleeding or hematoma formation at the catheterization site. However, since the dressing is reported to be dry and intact, and the client is experiencing systemic symptoms, the priority is to assess for potential systemic complications first.
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.