The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

Perform active range of motion three times daily.

Maintain the head of bed in a flat or 30 degree position.

Teach measures to avoid the Valsalva maneuver.

Monitor for Battle's sign every four hours.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Performing active range of motion exercises may not be safe or appropriate immediately following a hemorrhagic stroke.

Choice B rationale: Maintaining the head of bed flat or at a 30-degree position might be used for ischemic strokes but not necessarily for hemorrhagic strokes.

Choice C rationale: Teaching measures to avoid the Valsalva maneuver (straining during activities like defecation) helps prevent sudden increases in intracranial pressure, which can be detrimental after a hemorrhagic stroke.

Choice D rationale: Monitoring for Battle's sign (bruising behind the ears associated with basilar skull fracture) is not relevant in the care of a hemorrhagic stroke.

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Correct Answer is B

Explanation

Choice A rationale: This does not match the peak time of NPH insulin.
Choice B rationale: This does not match the peak time of NPH insulin.
Choice C rationale: This does not match the peak time of NPH insulin.
Choice D rationale: This is because NPH insulin is an intermediate-acting insulin that has an onset of action of 1 to 2 hours, a peak of 6 to 12 hours, and a duration of 18 to 24 hours. Therefore, if Albert is given NPH insulin at 0730, the peak effect will occur between 1330 and 1930, which means that his blood glucose level will be lowest during this time.

A. arterial blood gas (ABG) findings B. oxygen saturation level C. white blood cell differential D. red blood cells (RBCs) and hemoglobin count findings

Correct Answer is A

Explanation

Choice A rationale: Arterial blood gas (ABG) findings provide direct information about oxygenation and acid-base balance in the blood, which can indicate hypoxemia and metabolic acidosis.

Choice B rationale: Oxygen saturation level provides information about oxygen saturation in the blood but doesn't give a complete assessment of acid-base balance or other gases in the blood.

Choice C rationale: White blood cell differential assesses different types of white blood cells and is not directly related to evaluating hypoxemia or metabolic acidosis.

Choice D rationale: Red blood cells (RBCs) and hemoglobin count findings are important but do not directly assess hypoxemia or metabolic acidosis.

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The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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