A nurse is caring for a patient who suddenly experiences right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face.

After reporting these findings to the healthcare provider, the nurse receives several prescriptions for the patient, including an immediate CT scan of the head.

What should be the nurse’s first course of action?

Initiate two large-bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy.

Begin continuous observation for transient episodes of neurological dysfunction.

Elevate the head of the bed to 30 degrees, keeping the head and neck in neutral alignment.

Administer aspirin to prevent further clot formation and platelet aggregation.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.

Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale
The absence of coarse crackles is not necessarily an indication that chest physiotherapy (CPT) has been effective for a client with chronic obstructive pulmonary disease (COPD). Coarse crackles are often heard in conditions where there is fluid in the airways, such as pneumonia or heart failure. While their absence might indicate that there is no fluid in the airways, it does not necessarily mean that secretions have been effectively mobilized.
Choice B rationale
An increase in breath sounds is a good indication that chest physiotherapy (CPT) has been effective for a client with COPD3. CPT is a group of therapies designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system. When these secretions are effectively mobilized and removed, breath sounds can become clearer and more easily heard.
Choice C rationale

The absence of fine crackles is not necessarily an indication that CPT has been effective for a client with COPD. Fine crackles are often heard in conditions where there is fluid in the airways or alveoli, such as pneumonia or heart failure. While their absence might indicate that there is no fluid in the airways or alveoli, it does not necessarily mean that secretions have been effectively mobilized.
Choice D rationale
An increase in respiratory rate is not necessarily an indication that CPT has been effective for a client with COPD. In fact, an increased respiratory rate could indicate respiratory distress, which could suggest that the therapy has not been effective or that the client’s condition has worsened.

A. Ask the UAP to take the blood pressure in the other arm. B. Tell the UAP to use a different sphygmomanometer. C. Review the client’s serum calcium level. D. Administer a PRN antianxiety medication.

Correct Answer is C

Explanation

Choice A rationale
While taking the blood pressure in the other arm might avoid the spasms, it does not address the underlying cause of the spasms. Therefore, this is not the best action for the nurse to take.
Choice B rationale

Using a different sphygmomanometer would not necessarily prevent the spasms from occurring. The spasms are likely not caused by the equipment itself, but rather a physiological issue within the client.
Choice C rationale
The spasms in the client’s hand and fingers could be a sign of hypocalcemia, a condition where there is not enough calcium in the blood. One of the symptoms of hypocalcemia is muscle spasms or tetany. Therefore, reviewing the client’s serum calcium level would be an appropriate action to take.
Choice D rationale
Administering a PRN antianxiety medication would not address the underlying cause of the spasms. While anxiety can cause muscle tension and spasms, there is no indication in the scenario that anxiety is the cause of this client’s symptoms.

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Naxlex Comprehensive Predictor Exams

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. Following the therapy, which finding indicates to the nurse that the intervention was effective?

Correct Answer is B

Explanation

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Correct Answer is C

Explanation

A nurse in the emergency department is collecting evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most crucial for the nurse to implement?

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?

In the context of caring for a client diagnosed with psoriasis, which action by the nurse would address the client’s psychosocial need for acceptance?