A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

The client is consuming 25% of their meals.

The client coughs frequently while eating.

The client's blood pressure is 142/94 mm Hg.

The client leans to the left side while sitting.

Answer and Explanation

The Correct Answer is B

A. The client is consuming 25% of their meals.

Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.

B. The client coughs frequently while eating.

Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.

C. The client's blood pressure is 142/94 mm Hg.

The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.

D. The client leans to the left side while sitting.

Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Assist the client with a bowel cleansing.A bowel cleansing is necessary before an intravenous pyelogram (IVP) to ensure the urinary tract is clearly visualized on the X-ray images. Residual stool or gas in the intestines can obscure the view of the kidneys, ureters, and bladder.

B.Ensure the client is free of metal objects.While ensuring the client is free of metal objects is critical for procedures involving magnetic resonance imaging (MRI) or X-rays of the skeletal system, it is not specifically required for an IVP.

C.Monitor the client for pain in the suprapubic region.Monitoring for suprapubic pain is more relevant after procedures such as catheterization or bladder studies, or in cases of suspected urinary retention or infection.

D.Administer 240 mL (8 oz) of oral contrast before the procedure.An IVP involves injecting contrast dye intravenously, not orally. Oral contrast is typically used for gastrointestinal studies, such as a CT scan of the abdomen or barium swallow.

A. Gown B. Gloves C. Mask D. Eyewear

Correct Answer is B

Explanation

A. Gown:

After removing gloves, the gown should be taken off. The gown is considered the second most contaminated item. It is important to avoid contact with the outer surface of the gown while removing it.

B. Gloves:

Gloves should be removed first because they are the most likely part of the PPE to be contaminated. Care should be taken to avoid touching the outside of the gloves, and they should be disposed of properly.

C. Mask:

The mask is removed next. Care should be taken to handle the mask by the ties or ear loops without touching the front surface. Removing the mask last helps protect the nurse from potential respiratory droplets on the mask.

D. Eyewear/Face Shield:

Eyewear or face shield is removed last. Similar to the other components, it should be handled carefully to prevent self-contamination. This step helps protect the eyes and face from any potential splashes or airborne particles.

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A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

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