A nurse is attending to a patient who suddenly experiences numbness and weakness on the right side of their body, including their arm and leg.

The nurse also observes a distinct droop on the right side of the patient’s face.

After reporting these findings to the healthcare provider, the nurse receives several prescriptions for the patient, including an immediate CT scan of the head.

What should be the nurse’s first course of action?

Initiate two large-bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy.

Start continuous observation for transient episodes of neurologic dysfunction.

Elevate the head of the bed to 30 degrees, keeping the head and neck in neutral alignment.

Administer aspirin to prevent further clot formation and platelet aggregation.

Answer and Explanation

The Correct Answer is A

Choice A rationale
If a patient suddenly experiences numbness and weakness on the right side of their body, including their arm and leg, and a distinct droop on the right side of the patient’s face, these are warning signs of a stroke. The nurse’s first course of action should be to initiate two large- bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy. This is because rapid administration of fibrinolytic therapy can significantly improve outcomes in patients with acute ischemic stroke.
Choice B rationale
Continuous observation for transient episodes of neurologic dysfunction is important, but the immediate priority is to prepare for potential fibrinolytic therapy.
Choice C rationale
Elevating the head of the bed to 30 degrees and keeping the head and neck in neutral alignment can be beneficial in certain situations, but it is not the immediate priority in this scenario.

Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with acute coronary syndrome or those at high risk of cardiovascular disease.
However, in the case of a suspected stroke, immediate medical evaluation and potential fibrinolytic therapy are the priorities.

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Correct Answer is C

Explanation

Choice A rationale
While the color, clarity, and odor of urine can provide important information about a patient’s overall health and hydration status, it is not the most crucial information to obtain before inserting an indwelling urinary catheter.
Choice B rationale
The patient’s ability to increase fluid intake can be important in managing various health conditions, but it is not the most important information to obtain before this procedure.
Choice C rationale
Knowing if a patient has allergies to antiseptic solutions is crucial before inserting an indwelling urinary catheter. Using an antiseptic solution that a patient is allergic to can lead to serious complications.
Choice D rationale
While a previous history of urinary tract infections can inform the care and management of a patient with an indwelling urinary catheter, it is not the most important information to obtain before the procedure.

A. Administer IV fluids B. Assess the rash C. Administer an antihistamine D. Administer a steroid

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

Explanation

Choice A rationale
Administering IV fluids is a potential nursing intervention for several body systems. For example, the circulatory system may require IV fluids to maintain blood volume and pressure. The renal system may need IV fluids to ensure adequate urine output. The digestive system might need IV fluids to compensate for losses from vomiting or diarrhea.
Choice B rationale
Assessing a rash is a potential nursing intervention for the integumentary system. Rashes can be a sign of many different conditions, including allergic reactions, infections, autoimmune diseases, and more. By assessing the rash, the nurse can gather information to help determine its cause and appropriate treatment.
Choice C rationale
Administering an antihistamine is a potential nursing intervention for the immune system. Antihistamines are often used to treat allergic reactions, which involve the immune system.

They can also be used to treat symptoms of the common cold, which is caused by a viral infection.
Choice D rationale
Administering a steroid is a potential nursing intervention for several body systems. Steroids can be used to reduce inflammation, which can benefit the musculoskeletal, integumentary, respiratory, and other systems. They can also be used to treat certain endocrine disorders.

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Naxlex Comprehensive Predictor Exams

Before inserting an indwelling urinary catheter, which information about the patient is most important for the nurse to obtain?

Correct Answer is C

Explanation

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

Explanation

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