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. Walk to the other side of the bed and try again: The patient may have right-sided neglect due to the stroke, meaning they are not aware of stimuli on the left side. Approaching from the other side where the patient has better perception might help them respond better.
B. Wave a hand in front of the patient's face: This might not be effective and can startle the patient. It does not address the underlying issue of spatial neglect.
C. Speak more loudly and clearly: There is no indication that the patient has hearing loss or language comprehension issues. Speaking louder may not be effective if the patient is experiencing spatial neglect.
D. Use a picture board to explain to the patient what the nurse is going to do: This is a good strategy for communication but does not address the immediate need to reposition to a more effective approach to gain the patient’s attention first.

A. Ensure an adequate potassium blood level. B. Gradually reduce BP. C. Negate the impact of sodium in the body. D. Increase urine output.

Correct Answer is B

Explanation

A. Ensure an adequate potassium blood level.: While potassium levels are important, they are not the primary goal in a hypertensive emergency.
B. Gradually reduce BP.: In hypertensive emergencies, the goal is to gradually reduce blood pressure to avoid causing further damage to organs. Rapid reduction can lead to ischemia or stroke.
C. Negate the impact of sodium in the body.: Although reducing sodium intake is a general recommendation for hypertension management, it is not the immediate goal in an emergency situation.
D. Increase urine output.: While diuretics might be used, the main goal is the controlled reduction of blood pressure rather than just increasing urine output.

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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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