A patient has been admitted with an ischemic stroke. The patient received recombinant tissue plasminogen activator (rtPA) in the emergency department
The nurse checks the medication administration record to make sure the patient does not have which medications for the next 24 hours? (Select all that apply.) a. Aspirin
b. Sodium nitroprusside
c. Warfarin
d. Labetalol
e. Any antiplatelet drugs
A, C, E
The major risk and complication of rtPA therapy is bleeding, especially intracranial hemorrhage. Unlike fibrinolytic protocols for acute myocardial infarction, subsequent therapy with anticoagulant or antiplatelet agents is not recommended after rtPA administration in ischemic stroke. Patients receiving fibrinolytic therapy for stroke should not receive aspirin, heparin, warfarin, ticlopidine, or any other antithrombotic or antiplatelet drugs for at least 24 hours after treatment. Sodium nitroprusside and labetalol are used to manage blood pressure after a stroke.
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A patient's laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland
a. Thyroid b. Parotid c. Adrenal d. Parathyroid
A woman in her ninth month of pregnancy is in the ICU, recovering from surgery to remove a stage 1 tumor from her brain. She is still under the effects of general anesthesia
As the nurse is taking her vital signs, the woman regurgitates some fluid from her mouth. What is the most likely cause of the regurgitation? A) Esophageal cancer B) Displacement of the esophageal sphincter C) Airway obstruction D) Congenital defect of the esophagus
After a care provider has explained a procedure to the client, the client seems confused. Ethically, what is the nurse's next action?
1. The nurse should sign the document witnessing the client's signature. 2. The nurse should assess understanding, since the client appears confused. 3. The nurse should have the care provider come back and answer any questions the client has. 4. The nurse needs to go over the procedure again, answering any questions afterwards.
If a patient has been drinking hot coffee, how long should you wait before taking the temperature orally?
A) 5 minutes B) 15 minutes C) 20 minutes D) 30 minutes