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 D

Explanation

A. Instruct the patient to wear constrictive clothing: This is incorrect. Constrictive clothing can impede blood flow and worsen venous stasis.
B. Encourage frequent ambulation: This is correct. Ambulation promotes circulation, helps prevent blood stasis, and encourages the healing of ulcers.
C. Encourage the patient to keep legs in a dependent position: This is incorrect. Keeping the legs in a dependent position can increase venous pressure and exacerbate edema, which is counterproductive for managing venous stasis ulcers.
D. Apply compression stockings: This is correct. Compression stockings help to improve venous return, reduce edema, and promote ulcer healing by preventing blood from pooling in the legs.

A. TIA B. Stroke C. CVA D. OSAH

Correct Answer is A

Explanation

A. TIA: A transient ischemic attack (TIA) is characterized by temporary symptoms due to a brief period of reduced blood flow to the brain, with no lasting damage.
B. Stroke: A stroke involves a more prolonged interruption of blood flow to the brain and typically results in permanent neurological damage.
C. CVA: Cerebrovascular accident (CVA) is another term for stroke, involving sustained damage.
D. OSAH: This is not a relevant term or acronym for the condition described. It is not related to cerebral circulation impairment.

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