The nurse is caring for a client who reports a sudden, severe facial numbness. The nurse observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left.

The client denies a recent history of headaches or trauma.

Which intervention should the nurse perform immediately?

Maintain elevated positioning of the dependent joints on the affected side.

Verify prescribed laboratory tests include prothrombin time and platelet count.

Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Administer aspirin to prevent further clot formation and platelet clumping.

Answer and Explanation

The Correct Answer is C

Choice A rationale
While maintaining elevated positioning of the dependent joints on the affected side can be helpful in certain conditions such as edema or injury, it is not the immediate intervention needed for a client presenting with sudden, severe facial numbness, uneven smile with facial droop to the right side, and a hand grasp strength that is weaker on the right than the left.
Choice B rationale
Verifying prescribed laboratory tests including prothrombin time and platelet count is important in assessing the client’s coagulation status. However, it is not the immediate intervention needed in this situation.
Choice C rationale
The client’s symptoms are suggestive of a stroke. In such cases, immediate medical intervention is crucial. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an appropriate immediate intervention.
Choice D rationale
Administering aspirin can be beneficial in preventing further clot formation and platelet clumping in clients at risk of a stroke. However, it is not the immediate intervention needed in this situation.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale
Cold and dry skin can be a symptom of hypothyroidism, but it’s not typically a sign that requires immediate action.
Choice B rationale
Facial puffiness and periorbital edema can be symptoms of hypothyroidism, but they’re not typically signs that require immediate action.
Choice C rationale
A hematocrit of 30% (0.30 volume fraction) is lower than the normal range, indicating anemia. While this is a concern and should be addressed, it’s not typically a sign that requires immediate action in the context of hypothyroidism.
Choice D rationale
A further decline in the level of consciousness can be a serious sign of deteriorating health in a client with hypothyroidism and should be acted upon immediately.

Correct Answer is ["125"]

Explanation

Step 1 is to convert the volume of the prescription from liters to milliliters. 1 liter is equal to 1000 mL. So, the prescription is for 1000 mL of lactated Ringer’s.

Step 2 is to divide the total volume by the total time. The prescription is to be infused over 8 hours. So, 1000 mL ÷ 8 hours = 125 mL/hr. Therefore, the nurse should program the infusion pump to deliver 125 mL/hr.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?

Correct Answer is D

Explanation

A client receives a prescription for 1 liter of lactated Ringer’s intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?

Correct Answer is ["125"]

Explanation

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