Nokea
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first:
- A. Ask what medications the client is taking.
- B. Complete a history and health assessment.
- C. Identify the time of onset of the stroke.
- D. Determine if the client is scheduled for any surgical procedures.
Correct Answer: C
Rationale: The time of stroke onset is critical for t-PA administration, as it must be given within a specific window (typically 3-4.5 hours) to be effective and safe. Other assessments follow this priority.
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When a client with thrombocytopenia has a severe headache, the nurse interprets that this may indicate which of the following?
- A. Stress of the disease.
- B. Cerebral bleeding.
- C. Migraine headache.
- D. Sinus congestion.
Correct Answer: B
Rationale: Thrombocytopenia increases the risk of bleeding, and a severe headache may indicate cerebral bleeding, a life-threatening complication. The nurse should prioritize this possibility over stress, migraine, or sinus issues, which are less likely in this context.
Which of the following is a priority goal for the client with chronic obstructive pulmonary disease (COPD)?
- A. Maintaining functional ability.
- B. Minimizing chest pain.
- C. Increasing carbon dioxide levels in the blood.
- D. Treating infectious agents.
Correct Answer: A
Rationale: Maintaining functional ability is a priority in COPD to preserve quality of life and independence. Chest pain is not a primary issue. Increasing CO2 is harmful. Treating infections is important but not the top goal.
The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.
- A. The family is coming in to visit.
- B. The client has increased secretions requiring frequent suctioning.
- C. The SpO2 and PO2 have decreased.
- D. The client is tachycardic with drop in blood pressure.
- E. The face has increased skin breakdown and edema.
Correct Answer: C,D,E
Rationale: Decreased SpO2/PO2 (C), tachycardia with hypotension (D), and facial skin breakdown/edema (E) indicate complications requiring a return to supine position. Family visits and suctioning needs are manageable in prone position.
College freshman are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on:
- A. Water sanitation.
- B. Single dormitory rooms.
- C. Vaccine for hepatitis B.
- D. Safe sexual practices.
Correct Answer: D
Rationale: Hepatitis B is transmitted through blood and body fluids, so safe sexual practices (D) are critical for prevention. Water sanitation (A) is relevant for hepatitis A, single rooms (B) are unnecessary, and while vaccination (C) is important, the question focuses on behavioral instruction.
The client's wife asks the nurse whether the I.V. infusion is meeting her husband's nutritional needs because he has vomited several times. The nurse's response should be based on the knowledge that 1 L of 5% dextrose in normal saline solution delivers:
- A. 170 calories.
- B. 250 calories.
- C. 340 calories.
- D. 500 calories.
Correct Answer: A
Rationale: One liter of 5% dextrose provides 50 g of dextrose, yielding approximately 170 calories, insufficient for full nutritional needs.