The nurse is preparing to administer alteplase (Activase). In order for this medication to be effective in treating a thrombolytic stroke, when must the medication be administered?
1. 6 hours prior to symptoms
2. 3 hours prior to symptoms
3. 24
4. 12
2
Rationale 1: Alteplase must be given within 3 hours of thrombotic stroke to be effective.
Rationale 2: Alteplase must be given within 3 hours of thrombotic stroke to be effective.
Rationale 3: Alteplase must be given within 3 hours of thrombotic stroke to be effective, not 24 hours.
Rationale 4: Alteplase must be given within 3 hours of thrombotic stroke to be effective, not 12 hours.
Global Rationale: Alteplase must be given within 3 hours of thrombotic stroke to be effective.
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A nurse reads in the chart that a baby has a positive crossed extension reflex and asks a more experienced nurse to demonstrate this assessment. How does the nurse perform the assessment?
A. Place the infant supine, stimulate one foot, and watch for reaction of the other leg. B. Tap the infant's forehead gently, and assess for blinking for the first few taps. C. Watch the infant attempt to crawl when he is placed on his abdomen. D. With the infant prone, stroke one side of the spine; watch the buttocks curve toward the stimulation.
The nurse is caring for a patient with moderate Alzheimer disease. What nursing intervention best promotes communication?
1. Keep a consistent daily routine. 2. Limit the number of food choices. 3. Give the patient step-by-step instructions. 4. Correct the patient when experiencing a hallucination.
The nurse gently touches the shoulder of a patient lying with eyes closed. When the patient opens his eyes, the nurse smiles and asks how he is feeling. Which kind of touch is this?
A. Caring B. Protective C. Task-oriented D. Healing touch
A patient who has hypertension is taking a thiazide diuretic. The patient has a serum uric acid level of 8 mg/dL. The primary care nurse practitioner (NP) caring for this patient should:
a. prescribe colchicine. b. discontinue the thiazide diuretic. c. order a 24-hour urine collection. d. refer the patient to a rheumatologist.