The nurse is caring for a client who arrives at the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. After obtaining vital signs, the nurse should implement which intervention?

Initiate bilateral intermittent sequential pneumatic compression devices.

Place an indwelling urinary catheter and measure strict intake and output.

Notify the stroke team to assist with acute assessment and management.

Administer aspirin to prevent further clot formation and platelet clumping.

Answer and Explanation

The Correct Answer is C

Choice A reason: While pneumatic compression devices are used for DVT prevention, they are not the immediate intervention for suspected stroke.

Choice B reason: Placing an indwelling urinary catheter is not the first-line intervention for a patient with suspected stroke symptoms.

Choice C reason: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.

Choice D reason: Aspirin may be used in the management of stroke, but only after a stroke has been confirmed and not as an immediate intervention.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

- Choice A: No Understanding

- Reason: An echocardiogram is a non-invasive procedure that uses ultrasound waves to create images of the heart.

- Choice B: Understanding

- Reason: Parents can indeed show their child a movie or read a book during the procedure as it helps keep the child calm and still, which is conducive for a transthoracic echocardiogram².

- Choice C: No Understanding

- Reason: An echocardiogram is generally not a painful procedure. It is non-invasive and involves placing a transducer on the chest to capture images of the heart².

- Choice D: Understanding

- Reason: The echocardiogram will indeed produce an image of the structure of the heart, which is essential for diagnosing and assessing conditions like VSD.

- Choice E: Understanding

- Reason: Echocardiography uses sound waves to produce images of the heart, which can show how well blood is moving through the heart and heart valves.

A. Teach the client to use an incentive spirometer every 2 hours while awake. B. Administer low molecular weight heparin as prescribed. C. Assess the pain level and medicate as needed, as prescribed. D. Maintain sequential compression devices while in bed. E. Remove the urinary catheter as soon as possible and encourage voiding.

Correct Answer is ["A","E"]

Explanation

The correct answer is: A. Teach the client to use an incentive spirometer every 2 hours while awake and E. Remove the urinary catheter as soon as possible and encourage voiding.

Choice A reason:

Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent postoperative pulmonary complications such as pneumonia. This intervention promotes lung expansion and clears secretions, reducing the risk of infection.

Choice B reason:

Administering low molecular weight heparin as prescribed is important for preventing deep vein thrombosis (DVT) and pulmonary embolism, but it does not directly reduce the risk of infection.

Choice C reason:

Assessing the pain level and medicating as needed is crucial for patient comfort and mobility, but it does not directly address infection prevention. Effective pain management can indirectly support recovery by enabling better mobility and respiratory function.

Choice D reason:

Maintaining sequential compression devices while in bed is aimed at preventing DVT, not infections. These devices help improve blood circulation and reduce the risk of blood clots.

Choice E reason:

Removing the urinary catheter as soon as possible and encouraging voiding reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal of the catheter minimizes the duration of exposure to potential pathogens, thereby reducing infection risk.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits After the physician orders the echocardiogram, the nurse educates the parents about the procedure. For each statement below, indicate whether it shows understanding or a lack of understanding by the parents.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

An older adult client is admitted for the repair of a broken hip. To reduce the risk of infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? Select all that apply.

Correct Answer is ["A","E"]

Explanation

A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome indicates that the program was effective?

An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with a possible methicillin-resistant Staphylococcus aureus (MRSA) infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis?

Patient Data Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal defect via cardiac catheterization. What should the nurse’s focused assessment include before the cardiac catheterization? Select all that apply.

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?