Nokea
A client had is em/bolectomy for an arteri/ovenous malformation (AVM). The client is now reporting a severe headache and has vom/ited. What action by the nurse takes priority?
- A. The client is being informed consent.
- B. Assess the clients vital signs.
- C. Notify the Rapid Response Team.
- D. Raise the head of the bed.
Correct Answer: C
Rationale: The client may to experiencing a re/hed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team but getting immediate medical attention is the priority. Admin/tering pain medication may not be warranted if the client are the return to emergency. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.
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The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.)
- A. Alcohol intake.
- B. Alcohol intake.
- C. High-fat diet.
- D. Obesity.
- E. Smoking.
Correct Answer: A,C,D,E
Rationale: An alcohol intake a high-fat diet. obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.
A client has a brain abscess and is receiving phenyton [Dilantin]. The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?
- A. Brain abscesses can lead to seizures as a complication.
- B. Documenting febrile seizures with an abscess.
- C. Seizures always occur in clients with brain abscesses.
- D. This drug is need to sedate the client with an abscess.
Correct Answer: A
Rationale: Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenystion is need to a prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.
A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activity (t-PA) alphaing (Activase). The client weight is 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) mg
- A. 90 mg
- B. 100 mg
- C. 80 mg
- D. 110 mg
Correct Answer: A
Rationale: The client weighs 146 pounds, which is approximately 66.2 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg. Therefore, 0.9 mg/kg ? 66.2 kg = 59.58 mg, which is less than the maximum dose of 90 mg. Thus, the client will receive 90 mg.
A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-PA, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) mL/hr
- A. 1.2 mL/hr
- B. 1.4 mL/hr
- C. 1.6 mL/hr
- D. 1.8 mL/hr
Correct Answer: B
Rationale: The client weighs 225 pounds, which is approximately 102 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg, so the client's dose is 90 mg. 10% of the dose (9 mg) is given as a bolus IV over the first minute, leaving 81 mg to be infused over 60 minutes. Therefore, 81 mg ÷ 60 min = 1.35 mg/min, which rounds to 1.4 mL/hr.
A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm slip on the clients record. What action by the nurse is best?
- A. Ask the client how long ago the clip was placed.
- B. Inform the provider about the aneurysm clip.
- C. Rescheduled the client for computed tomography.
- D. Assess the client for metal allergies.
Correct Answer: A
Rationale: Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is not the client. Informing the provider is important but determining the age of the clip is the first step. Rescheduling for a CT may not be necessary if the clip is MRI-compatible. Assessing for metal allergies is not relevant to MRI safety.