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    HESI RN EXIT 3 PROCTORED EXAM

    The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. Which action should the nurse take first?

    Explanation & Rationale

    A. Administer aspirin to prevent further clot formation and platelet clumping. While aspirin may be indicated in the treatment of ischemic stroke, it is not the immediate priority. The client requires further assessment and diagnostic evaluation before initiating specific treatments. B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. Positioning the client is important for maintaining airway patency, but it is not the priority when assessing and managing acute stroke. Immediate interventions to address potential thrombolytic therapy take precedence. C. Begin continuous observation for transient episodes of neurologic dysfunction. Continuous observation is important for monitoring the client's neurological status, but it is not the first action to take. The client requires urgent diagnostic imaging to confirm the diagnosis and determine eligibility for thrombolytic therapy. D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. This is the priority action. IV access is crucial for administering medications and fluids, and reviewing the inclusion criteria for IV fibrinolytic therapy is essential to determine if the client meets the criteria for this time-sensitive intervention.

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