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

an ischemicstroke. 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 venousdrainage, ATI page 89)

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

the followinginstructions 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 ofthe 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 implytotal obstruction. QSEN: Safety (Book page 1143)

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

following medicationsshould the nurse plan to administer?

-Regular Insulin

-Furosemide

-Desmopressin

-Lithium Carbonate

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

desmopressin orally orby nasal spray.

Management focuses on controlling symptoms with drug therapy.

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

of vasopressingiven 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 mcgand 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.