The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Obtain an electrocardiogram (ECG) exam

Obtain intravenous access

Administer 2 L of oxygen per nasal cannula

Obtain a rectal temperature

Answer and Explanation

The Correct Answer is C

A. Obtain an electrocardiogram (ECG) exam: While an ECG is important to assess cardiac status, it is not the immediate priority compared to addressing the low oxygen saturation.
B. Obtain intravenous access: IV access is important for administering medications and fluids but does not take precedence over addressing hypoxia.
C. Administer 2 L of oxygen per nasal cannula: This is correct. The priority is to improve oxygenation since hypoxia can exacerbate neurological damage in a stroke patient. An SpO2 of 88% is low and requires immediate correction to prevent further complications.
D. Obtain a rectal temperature: Temperature assessment is not as urgent as addressing the immediate need for oxygen to improve SpO2 levels.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Paresthesia: Numbness or tingling sensations (paresthesia) can occur due to decreased blood supply and nerve function.
B. Pruritus: Itching (pruritus) is not typically associated with arterial occlusion. It is more often related to skin conditions or allergies.
C. Pain: Pain is a hallmark symptom of arterial occlusion, often described as severe and sudden, due to tissue ischemia.
D. Pallor: Affected limbs or areas may appear pale (pallor) because of reduced blood flow.
E. Palpitations: Palpitations are not a direct symptom of arterial occlusion. They are more related to cardiac conditions.

A. Ecchymosis B. Stasis ulcers C. Angina D. Intermittent claudication

Correct Answer is D

Explanation

A. Ecchymosis: Ecchymosis (bruising) is not a typical symptom of peripheral arterial occlusive disease. It generally indicates bleeding or trauma to the skin and subcutaneous tissues.
B. Stasis ulcers: Stasis ulcers are associated with chronic venous insufficiency, not peripheral arterial disease.
C. Angina: Angina refers to chest pain due to reduced blood flow to the heart, and it is associated with coronary artery disease, not peripheral arterial occlusive disease.
D. Intermittent claudication: This is the classic symptom of peripheral arterial occlusive disease, characterized by muscle pain or cramping in the legs triggered by physical activity and relieved by rest. It is due to insufficient blood flow to the muscles during exercise.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are clinical manifestations of arterial occlusion? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse would evaluate the patient as understanding reinforcement of teaching for peripheral arterial occlusive disease if the patient stated that which of the following is the classic symptom?

Correct Answer is D

Explanation

The nurse is providing care for a patient with expressive aphasia. Which intervention does the nurse expect to find in the patient's plan of care? (Select all that apply.)

A patient asks the difference between osteoarthritis and RA. Which manifestations does the nurse explain are characteristic of RA? (Select all that apply.)

The nurse is caring for a patient with venous stasis ulcers. What action should the nurse take?

The LPN/LVP is discussing types of hypertension with a patient. Which statement by the patient would reflect understanding of secondary hypertension?

The nurse is providing education about the warning signs of stroke to a nursing student. Which information would be appropriate for the nurse to include in the teaching?

The nurse is planning care for patients with hypertension. What side effect should be included with teaching about the beta blocker propranolol (Inderal)?

The nurse is reinforcing teaching provided to a patient with Raynaud disease. Which measure should the nurse include to prevent an attack?

The nurse is caring for a group of patients. Which patient is the priority?