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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.
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After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 m/mr. What action by the nurse is best?
- A. Assess the client needs care.
- B. Assess the clients sodium level.
- C. Increase the rate of the IV infusion.
- D. Provide the care every hour.
Correct Answer: B
Rationale: This client has manifestations of hypermatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessment/inursing records.
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beat/min, pulse pressure increase from 26 to 40 min $\mathrm{Hg}$, and respiratory irregularities. What action by the nurse takes priority?
- A. Call the spouse of a Rapid Response Team.
- B. Increase the rate of the IV fluid administration.
- C. Notify respiratory therapy for a breathing treatment.
- D. Prepare to give IV pain medication.
Correct Answer: A
Rationale: These manifestations indicate Cushing syndrome, a potentially life-threatening increase in intracranial trauma (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment and pacion medication.
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the de/ocate sodium (Col/ace) because the client had a large stool car/ifier. What action by the supervising nurse is best?
- A. Have the student ask the client if it is desired or not.
- B. Infer the the student that the de/ocate should be given.
- C. Tell the student to document the ration/ale.
- D. Tell the student to give it unless the client refuses.
Correct Answer: B
Rationale: A student nurse should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Val/aba's maneuver when cons/ist/ated. The supervising nurse should instruct the student to administer the docuscate. The other options are not appropriate. The medication could be held for diarrhea.
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.
A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (NAP) (Select all that apply.)
- A. Applying a cool washcloth to the head.
- B. Assitting the client to a position of comfort
- C. Keeping voices soft and soothing
- D. Maintaining low lighting in the room
- E. Providing antipyretics for fever
Correct Answer: A,B,C,D
Rationale: The client with meningitis often has high fever, pain, and some degree of confusion. Cool washclodts to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manager nurse. Key category low and light demand also helps convey caring in a nondroctioning manner. The nurse provides antipyretics for fever.