The nurse is caring for a patient recently admitted with a stroke. The patient is experiencing nausea and begins to vomit. Which of the following actions should the nurse take first?

Assist the patient to turn to her side.

Give an antiemetic as ordered.

Perform a test for blood on the emesis.

Call for an aide to get suction set up.

Answer and Explanation

The Correct Answer is A

A. Assist the patient to turn to her side: This is the priority action to prevent aspiration of vomitus, which can be a serious complication for stroke patients who may have impaired swallowing and a reduced gag reflex.
B. Give an antiemetic as ordered: While important, administering an antiemetic should come after ensuring the patient’s safety and preventing aspiration.
C. Perform a test for blood on the emesis: This is not the immediate priority. Preventing aspiration is the first concern.
D. Call for an aide to get suction set up: Suction may be necessary if the patient is at risk of aspiration, but the first step is to turn the patient to prevent choking and aspiration.

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Correct Answer is A

Explanation

A. I will walk 20 minutes every other day: This is correct. Walking is a safe, low-impact activity that promotes cardiovascular health without placing undue stress on the abdominal area, which is important for a patient with an AAA.
B. Instead of taking my car, I will ride my bike everywhere: Biking can be too strenuous and risky for someone with an AAA, as it may involve physical exertion and potential for trauma to the abdominal area.
C. I am starting back to work as a grocery store stocker next week: This job likely involves heavy lifting and significant physical activity, which is contraindicated for a patient with an AAA due to the risk of increased intra-abdominal pressure and potential aneurysm rupture.
D. I am going to continue my marathon training tomorrow: Marathon training is highly strenuous and can significantly increase blood pressure and stress on the abdominal region, posing a high risk of aneurysm rupture.

A. Monitor blood glucose levels. B. Lifestyle modifications and medication adherence will not prevent blindness, C. Lifestyle modifications can prevent strokes. D. End organ damage is inevitable because of microvascular changes that occur. E. Take medications as ordered.

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

Explanation

A. Monitor blood glucose levels: Patients with diabetes need to keep their blood glucose levels under control to prevent complications, including those that can exacerbate hypertension or lead to cardiovascular problems.
B. Lifestyle modifications and medication adherence will not prevent blindness: This is incorrect. Proper management of diabetes through lifestyle changes and medication adherence can help prevent complications like diabetic retinopathy, which can lead to blindness.
C. Lifestyle modifications can prevent strokes: Effective management of diabetes and hypertension through lifestyle changes (diet, exercise, smoking cessation) can significantly reduce the risk of strokes and other cardiovascular events.
D. End organ damage is inevitable because of microvascular changes that occur: This is misleading. While microvascular changes are a risk in diabetes, proper management and lifestyle modifications can greatly reduce the risk and progression of end-organ damage.
E. Take medications as ordered: Adherence to prescribed medications is crucial for controlling both blood glucose and blood pressure, reducing the risk of complications such as stroke, heart disease, and kidney damage.

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The nurse is caring for a patient recently admitted with a stroke. The patient is experiencing nausea and begins to vomit. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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