Nokea
The 68-year-old client is admitted to the emergency department with complaints of slurred speech, right-sided weakness, and ataxia. The emergency department physician ordered thrombolytic therapy for the client. Which action should the nurse implement first?
- A. Administer thrombolytic therapy via protocol.
- B. Send the client for a STAT CT of the head.
- C. Arrange for admission to the intensive care department.
- D. Check to determine if the client is cross sensitive to the thrombolytic.
Correct Answer: B
Rationale: A STAT head CT rules out hemorrhagic stroke, a contraindication for thrombolytics, and is the first step per stroke guidelines.
You may also like to solve these questions
The nurse is administering an otic drop to the 45-year-old client. Which procedure should the nurse implement when administering the drops?
- A. Place the drops when pulling the ear down and back.
- B. Place the drops when pulling the ear up and back.
- C. Place the drops in the lower conjunctival sac.
- D. Place the drops in the inner canthus and apply pressure.
Correct Answer: B
Rationale: For adults, pulling the ear up and back straightens the ear canal for otic drops. Down/back is for children, others are for ophthalmic drops.
You are caring for a client with deep vein thrombosis who is on Heparin IV. The latest APTT is 50 seconds. If the laboratory normal range is 16-24 seconds, you would anticipate
- A. maintaining the current heparin dose
- B. increasing the heparin as it does not appear therapeutic
- C. giving protamine sulfate as an antidote
- D. repeating the blood test 1 hour after giving heparin
Correct Answer: A
Rationale: maintaining the current heparin dose. The range for a therapeutic APTT is 1.5-2 times the control. Therefore the client is receiving a therapeutic dose of Heparin.
A 17-year-old client has been recently diagnosed as having diabetes mellitus Type 1. Insulin is prescribed. The client asks why insulin can't be taken by mouth. What is the best answer for the nurse to give?
- A. Insulin is irritating to the stomach.
- B. Oral insulin is too rapidly absorbed.
- C. Gastric juices destroy insulin.
- D. You can take it by mouth when the acute phase is over.
Correct Answer: C
Rationale: Insulin is a protein destroyed by gastric enzymes, requiring injection for effective delivery.
Aluminum hydroxide gel (Amphojel) is ordered for an adult who has acute renal failure. What is the primary reason for administering this drug to this client?
- A. To prevent the development of Curling's ulcers
- B. To bind phosphates
- C. To maintain normal pH
- D. To prevent diarrhea
Correct Answer: B
Rationale: In renal failure, aluminum hydroxide binds phosphates in the gut, reducing hyperphosphatemia, a common complication.
The client diagnosed with coronary artery disease is prescribed an HMG-CoA reductase inhibitor to help reduce the cholesterol level. Which assessment data should be reported to the health-care provider?
- A. Complaints of flatulence.
- B. Weight loss of two (2) pounds.
- C. Complaints of muscle pain.
- D. No bowel movement for two (2) days.
Correct Answer: C
Rationale: Muscle pain with statins may indicate myopathy or rhabdomyolysis, requiring urgent HCP reporting. Flatulence, weight loss, or constipation are less serious.