The nurse is caring for a client who reports a sudden, severe headache, and facial numbness.The nurse asks the client to smile and observes an uneven smile with a facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention?

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

Maintain elevated positioning of the dependent joints on affected side.

Raise the head of the bed to 30 degrees keep head and neck in neutral alignment.

Determine when symptoms began and if improved or worsened since onset.

Answer and Explanation

The Correct Answer is D

A)   Incorrect- While monitoring urinary output is important for overall assessment, it is not the most critical intervention in this situation of suspected stroke. The client's neurological symptoms take precedence.
B)   Incorrect- Positioning might be relevant to preventing complications, but it is not the highest priority intervention in this situation. The focus should be on assessing the client's neurological status and determining appropriate intervention.
C)   Incorrect- Although head positioning is relevant for intracranial pressure management, it is not the immediate priority. The nurse should first assess the time of symptom onset and determine if the client is experiencing an acute stroke.
D)   Correct- The client's symptoms, including sudden severe headache, facial numbness, facial droop, and weakness on one side, are suggestive of a stroke. The nurse should prioritize assessing the time of symptom onset, as time is a crucial factor in determining the appropriate intervention. Rapid intervention can improve outcomes in stroke cases, especially when considering interventions like thrombolytic therapy. The other options are not as directly relevant to the immediate management of a suspected stroke.

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Correct Answer is C

Explanation

- A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate.

- To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse.

- In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.

Therefore, option C is the correct answer, while options A, B, and D are incorrect.

Option A is incorrect because instructing the UAP to report any abnormal findings does not address the error in technique.

Option B is incorrect because reminding the UAP to check the pulse volume does not address the error in technique.

Option D is incorrect because confirming the accuracy of the pulse rate obtained by the UAP does not address the error in the technique.

A. Small gauze pad. B. Paper tape. C. Three mL syringe. D. Exam gloves. E. Sterile gloves.

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

Explanation

They are needed to remove the saline lock safely and prevent bleeding or infection. The PN should wear exam gloves to protect themselves and the client from contamination, apply a small gauze pad over the insertion site, and secure it with paper tape after removing the saline lock.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

Correct Answer is C

Explanation

The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

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

Explanation

An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever, and cough for the last two days Which finding should alert the nurse that the child is in acute respiratory distress?

The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding.

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review?

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure?

Before leaving the room of a confused client, the nurse notes that a half-bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?