The stroke team and primary nurse received CT scan results of their client experiencing an ischemic stroke. Which of the following interventions will the team do next?

Thrombolytic administration within 10 hrs

Complete neurologic assessment every 12 hrs

Alteplase administration within 4.5 hrs

Vancomycin administration after blood culture

Answer and Explanation

The Correct Answer is C

Choice A reason: Thrombolytic administration within 10 hours is incorrect, as the therapeutic window for thrombolytics like alteplase in ischemic stroke is typically 3–4.5 hours from symptom onset. Beyond this, the risk of hemorrhage outweighs benefits, making timely administration critical to restore cerebral blood flow and minimize brain damage.

Choice B reason: Completing neurologic assessments every 12 hours is important for monitoring but is not the next action post-CT confirming ischemic stroke. Urgent thrombolytic therapy (e.g., alteplase) within 4.5 hours takes priority to dissolve the clot, restore perfusion, and limit infarct size, improving neurological outcomes.

Choice C reason: Alteplase administration within 4.5 hours is the next step post-CT confirming ischemic stroke. This thrombolytic dissolves the clot obstructing cerebral blood flow, minimizing brain tissue damage. The narrow time window ensures efficacy and reduces hemorrhage risk, making it the priority intervention to improve stroke outcomes.

Choice D reason: Vancomycin administration after blood culture is irrelevant for ischemic stroke, which results from a clot, not infection. Antibiotics like vancomycin treat bacterial infections, not cerebral ischemia. The priority is thrombolytic therapy like alteplase to restore blood flow and prevent further brain tissue damage.

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Correct Answer is D

Explanation

Choice A reason: Wearing sunglasses is not an appropriate intervention for homonymous hemianopia, a visual field defect from stroke affecting the same side of both eyes. Sunglasses may reduce glare but do not address the loss of left visual field or help compensate for the neurological deficit.

Choice B reason: Scanning from left to right is incorrect for left homonymous hemianopia. This would prioritize the intact right visual field, neglecting the affected left side. Clients need to scan toward the affected side (right to left) to compensate for the visual loss and ensure awareness of their environment.

Choice C reason: Applying eye ointment is irrelevant for homonymous hemianopia, which results from brain damage (e.g., occipital lobe stroke) rather than ocular issues. Ointment may treat dry eyes or infections but does not address the neurological visual field defect caused by disrupted visual pathways.

Choice D reason: Teaching the client to scan from right to left is appropriate for left homonymous hemianopia. This compensates for the lost left visual field by training the client to actively turn their head toward the affected side, improving awareness of their environment and reducing collision risks.

A. Wearing the sequential compression device B. Elevating their feet C. Massaging their legs D. Ambulating soon after surgery

Correct Answer is C

Explanation

Choice A reason: Wearing a sequential compression device is recommended post-surgery to prevent venous thromboembolism. It promotes venous blood flow in the legs, reducing stasis, a key risk factor for clot formation. This action supports VTE prevention by enhancing circulation, making it appropriate and not to be avoided.

Choice B reason: Elevating the feet post-surgery aids venous return, reducing blood pooling in the legs, a risk factor for venous thromboembolism. This action decreases stasis and supports circulation, making it a beneficial practice for VTE prevention, not one to avoid in postoperative recovery.

Choice C reason: Massaging the legs should be avoided post-surgery, as it risks dislodging a formed clot, potentially causing a pulmonary embolism. In clients at risk for VTE, massage can mobilize thrombi from deep veins, leading to life-threatening complications, making this a critical action to avoid.

Choice D reason: Ambulating soon after surgery is encouraged to prevent venous thromboembolism. Early mobility promotes venous blood flow, reducing stasis, a major risk factor for clot formation. This action supports circulation and VTE prevention, making it appropriate and not something to avoid in postoperative care.

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The stroke team and primary nurse received CT scan results of their client experiencing an ischemic stroke. Which of the following interventions will the team do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client who has developed homonymous hemianopia affecting their left visual field after a stroke. Which of the following interventions is appropriate for this client?

Correct Answer is D

Explanation

A nurse is recovering a client who is postoperative. In an effort to educate the client about being at risk for developing a venous thromboembolism (VTE), which of the following actions should the client avoid?

Correct Answer is C

Explanation

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