1. A nurse is preparing to administer thrombolytic therapy to a client who had an ischemic

stroke. Which of the following is an appropriate nursing action?

-Start the therapy within 8 hrs. (within 6 hrs.)

-Insert an indwelling urinary catheter after therapy begins

-Monitor blood pressure every 30 minutes during infusion.

-Elevate the head of the bed between 25 and 30 degrees (to reduce ICP & promote venous

drainage, ATI page 89)

2. A nurse is teaching a client about the use of an incentive spirometer. Which of the following

instructions should the nurse include in the teaching?

-Place hands on the upper abdomen during inhalation.

-Exhale slowly through pursed lips.

-Hold breath about 3 to 5 seconds before exhaling. (ATI page 138)

-Position the mouthpiece 2.5 cm (1 in) from the mouth.

3. A nurse is assessing a client who is 12 hr. postoperative following a colon resection. Which of

the following findings should the nurse report to the surgeon?

-Heart rate 90/mm

-Hgb 8.2 g/dL

-Gastric ph of 3.0

-Absent bowel sounds

Recall that bowel sounds are altered in patients with obstruction; absent bowel sounds imply

total obstruction. QSEN: Safety (Book page 1143)

4. A nurse is caring for a client who has diabetes insipidus. Which of the following medications

should the nurse plan to administer?

-Regular Insulin

-Furosemide

-Desmopressin

-Lithium Carbonate

Teach patients with diabetes insipidus the proper way to self-administer desmopressin orally or

by nasal spray.

Management focuses on controlling symptoms with drug therapy.

-The most preferred drug is desmopressin acetate (DDAVP), a synthetic form of vasopressin

given orally, as a sublingual “melt,” or intranasally in a metered spray. The frequency of

dosing varies with patient responses. Teach patients that each metered spray delivers 10 mcg

and those with mild DI may need only one or two doses in 24 hours.

-For more severe DI, one or two metered doses two or three times daily may be needed.

5. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times

daily for 3 years. Which of the following test should the nurse monitor?

Stool occult blood

-Urine for white blood cells

-Fasting blood glucose

-Serum calcium