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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.
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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.
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?
- A. Client with cerebral perfusion measure of 72 mm Hg
- B. Client who has a Glasgow/ Com Scale score of 12
- C. Client with a PaCOO23 36 mm Hg who is on a ventilator
- D. Client who has a temperature of 102 F (38.9 C)
Correct Answer: D
Rationale: A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow/ Com Scale score of 12, a PaCOO of 36, and cerebral perfusion pressure of 72 mm Hg all desired outcomes.
A nursing student studying the neurologic system learns which information? (Select all that apply.)
- A. An aneurysm is a ballooning in a weakened part of an arterial wall.
- B. An arteriovenous malformation is the usual cause of the stroke.
- C. Intracerebral hemorrhage is bleeding directly into the brain.
- D. Reduced perfusion from vasospasm often makes stroke worse.
- E. Subarachnoid hemorrhage is caused by high blood pressure.
Correct Answer: A,C,D
Rationale: An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subbranchoid hemorrhage is usually caused by a ruptured aneurysm or AVM.
A nurse a caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first.
- A. Client who a Glasgow Coma Scale score that was 10 and is now is 8
- B. Client with a Glasgow Coma Scale score that was 9 and is now is 12
- C. Client with a moderate brain injury who is amnesia for the event
- D. Client who is respiratory pain medication for a headache.
Correct Answer: A
Rationale: A client decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement on the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the decline the Glasgow Coma Scale score.
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.