A client arrives in the emergency department with an ischemic stroke a

NCLEX RN Questions Medical Surgical Nursing

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Question 1 of 5.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first:

A. Ask what medications the client is taking.

B. Complete a history and health assessment.

C. Identify the time of onset of the stroke.

D. Determine if the client is scheduled for any surgical procedures.

Explanation: The time of stroke onset is critical for t-PA administration, as it must be given within a specific window (typically 3-4.5 hours) to be effective and safe. Other assessments follow this priority.

Question 2 of 5.

A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?

A. Monitor daily weights and urine output.

B. Permit unrestricted visitation by family and friends.

C. Provide client education on medications and diet.

D. Reduce pain and myocardial oxygen demand.

Explanation: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.

Question 3 of 5.

When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI is caused by:

A. Left ventricular overload.

B. Impending circulatory collapse.

C. Extracellular electrolyte imbalances.

D. Insufficient oxygen reaching the heart muscle.

Explanation: MI pain results from myocardial ischemia due to insufficient oxygen delivery to the heart muscle, caused by coronary artery occlusion.

Question 4 of 5.

Crackles heard on lung auscultation indicate which of the following?

A. Cyanosis.

B. Bronchospasm.

C. Airway narrowing.

D. Fluid-filled alveoli.

Explanation: Crackles indicate fluid in the alveoli, often due to pulmonary edema in heart failure or post-MI, reflecting left ventricular dysfunction.

Question 5 of 5.

A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to:

A. Decrease circulatory overload.

B. Improve the myocardial workload.

C. Prevent thrombus formation.

D. Regulate cardiac rhythm.

Explanation: Warfarin prevents thrombus formation, critical in atrial fibrillation and low ejection fraction, which increase clot risk due to stasis.