The nurse is caring for a client who had a thrombotic stroke in the Emergency Department. It has been less than 3 hours since the onset of symptoms. The rationale for using tissue plasminogen activator (t-PA) for this client is to:
reduce the risk of blood vessel spasm.
prevent platelet aggregation.
dissolve the blood clot.
prevent infection in the brain.
The Correct Answer is C
A. While blood vessel spasms can occur after a stroke, t-PA does not directly affect them.
B. Platelet aggregation is the process by which platelets stick together to form a clot. t-PA dissolves clots, but it does not prevent their formation.
C. Tissue plasminogen activator (t-PA) is a medication that can dissolve blood clots. In the case of a thrombotic stroke, a blood clot has blocked blood flow to the brain. By dissolving the clot, t-PA can restore blood flow and limit brain damage.
D. t-PA does not have any direct effect on the risk of infection in the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. After a radical cystectomy, the client may have a urinary diversion (such as a stoma) and should be vigilant about monitoring urine output. Absence of urine output can indicate a serious issue, and notifying the provider is crucial.
B. This statement indicates a need for further clarification. After a radical cystectomy, clients typically do not resume normal voiding because the bladder is removed. Instead, they may have a urinary diversion or need to learn how to manage their new urinary output. Normal voiding as before surgery is not possible, so this statement reflects a misunderstanding of the procedure's implications.
C. After surgery, particularly abdominal surgery like a radical cystectomy, patients are often advised to take stool softeners to prevent constipation. Straining can increase the risk of complications and affect the surgical site, so this is a valid precaution.
D. Monitoring the surgical site for signs of infection, such as redness, swelling, or discharge, is an essential part of post-operative care. Clients should be educated on how to check their surgical site for any concerning changes.
Correct Answer is C
Explanation
A. This value is within the normal range for adult males (14-17.3 g/dL) and borderline for females (11.7- 15.5 g/dL). While the specific context of the patient (e.g., gender) matters, generally, a hemoglobin level of 14 g/dL would not typically cause concern.
B. A platelet count of 150,000/mm³ is at the lower limit of normal (150,000-450,000/mm³). While this may be concerning in certain clinical contexts, it is still within the acceptable range and would not typically raise alarm for a post-op nephrectomy patient unless there are other indications of bleeding or clotting issues.
C. This white blood cell count is elevated (normal range is 4.5-11.1 x 10³/mm³). An elevated WBC count can indicate an infection, inflammation, or a response to surgery, which is particularly concerning post- operatively. This result would warrant further investigation to rule out infection, which is critical for recovery.
D. The neutrophil percentage of 59% is within the normal range (typically around 40-70% for total WBCs). While it is slightly elevated, it is not concerning on its own without additional context, especially since it may be elevated in response to surgery or stress.
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