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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dislocation injury: This refers to a joint being forced out of its normal position and is not related to strains.
B. Compression injury: This typically involves pressure that causes damage to a body part, such as crushing injuries, and does not describe a strain.
C. Muscle or tendon injury: A strain involves stretching or tearing of muscle or tendon fibers, making this the correct description of a strain.
D. Ligament injury: Injuries to ligaments are referred to as sprains, not strains.
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.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.