The nurse prepares to educate the client and spouse.
Click to select the 3 items that the nurse should include in the plan of care after administration of tissue plasminogen activator (tPA).

Maintain blood pressure at less than 180/105 mm Hg

Initiate deep vein thrombosis (DVT) prophylaxis

Prophylactically treat for potential seizures

Keep oxygen saturation greater than or equal to 92%

Normalize blood glucose levels

Answer and Explanation

Correct Answer : A,D,E

Rationale:
A. Maintain blood pressure at less than 180/105 mm Hg: After tPA administration, controlling blood pressure is critical to reduce the risk of intracerebral hemorrhage. Elevated pressures increase the likelihood of bleeding complications, so close monitoring and antihypertensive management are required.

B. Initiate deep vein thrombosis (DVT) prophylaxis: Pharmacologic DVT prophylaxis (e.g., heparin or enoxaparin) is contraindicated within the first 24 hours after tPA due to the risk of bleeding. Mechanical prophylaxis may be used, but medication should be delayed.

C. Prophylactically treat for potential seizures: Seizure prophylaxis is not routinely indicated after an ischemic stroke unless seizures occur. Administering anticonvulsants prophylactically does not prevent post-stroke seizures and may add unnecessary risk.

D. Keep oxygen saturation greater than or equal to 92%: Adequate oxygenation supports cerebral perfusion and reduces secondary ischemic injury. Monitoring and supplemental oxygen as needed is an essential component of post-tPA care.

E. Normalize blood glucose levels: Hyperglycemia worsens neurologic outcomes after stroke and can impair recovery. Blood glucose management within target ranges helps optimize neurologic recovery and reduces complications.

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Correct Answer is B

Explanation

Rationale:
A. Acknowledge that the PN has positioned the client safely and correctly: The flat prone position is not optimal for a sigmoidoscopy, as it may limit access to the rectum and visualization of the sigmoid colon. Simply acknowledging the position would not ensure procedural effectiveness.

B. Demonstrate to the PN how to position the client more effectively for the procedure: The proper position for a sigmoidoscopy is typically the left lateral (Sims’) position with knees flexed, which facilitates scope insertion and visualization. Demonstrating correct positioning promotes safe and effective care while supporting the PN’s learning.

C. Arrange for unlicensed assistive personnel to assist the PN during the procedure: Additional personnel may help with support, but correct client positioning is the priority for procedure success. Extra staff cannot compensate for improper positioning.

D. Assume care of the client and assign the PN to the care of a different client: While the nurse can take over if necessary, a collaborative teaching approach is preferred. Demonstrating proper technique improves team competence and maintains safe delegation.

A. The client's glycosylated hemoglobin A1C is below 7%. B. The client does not develop deep vein thrombosis (DVT) after abdominal surgery. C. The client's hemoglobin remains above 14 g/dL (140 g/L). D. The pulmonary embolus has lysed and the client's respiratory status improves.

Correct Answer is B

Explanation

Rationale:
A. The client's glycosylated hemoglobin A1C is below 7%: A1C reflects long-term blood glucose control, which is unrelated to the anticoagulant effects of enoxaparin. It does not indicate the medication’s effectiveness in preventing clot formation.

B. The client does not develop deep vein thrombosis (DVT) after abdominal surgery: Enoxaparin is a low-molecular-weight heparin used to prevent thrombus formation. The absence of DVT postoperatively demonstrates that the anticoagulant is achieving its intended prophylactic effect.

C. The client's hemoglobin remains above 14 g/dL (140 g/L): Hemoglobin levels indicate anemia status but are not a measure of anticoagulant effectiveness. While significant bleeding could lower Hgb, normal levels alone do not confirm therapeutic efficacy.

D. The pulmonary embolus has lysed and the client's respiratory status improves: Enoxaparin prevents new clot formation but does not actively lyse existing thrombi. Improvement in a pulmonary embolus would require other interventions, such as thrombolytic therapy.

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The nurse prepares to educate the client and spouse. Click to select the 3 items that the nurse should include in the plan of care after administration of tissue plasminogen activator (tPA).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is B

Explanation

While assessing a client's health history, the nurse notes that the client has been receiving enoxaparin. Which health outcome would indicate this medication is effective? Reference Range: Glycosylated hemoglobin (A1C) [4% to 5.9% ] Hemoglobin (Hgb) [12 to 16 g/dL (120 to 160 g/L)]

Correct Answer is B

Explanation

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The nurse prepares to educate the client and spouse.
Click to select the 3 items that the nurse should include in the plan of care after administration of tissue plasminogen activator (tPA).