A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority?

Change the client's position every 2 hr.

Place the client's right hand in a supination position.

Maintain NPO status for the client.

Perform range-of-motion exercises to the client's extremities.

Answer and Explanation

The Correct Answer is C

A. Change the client's position every 2 hr: Repositioning helps prevent skin breakdown and promotes circulation, which is important for stroke clients. However, it does not address the most immediate risk associated with right-sided weakness and facial drooping.

B. Place the client's right hand in a supination position: Proper positioning of the affected extremities prevents contractures and maintains joint alignment. While necessary for long-term care, it is not the highest priority in the immediate post-stroke period.

C. Maintain NPO status for the client: Right-sided weakness and facial drooping indicate potential dysphagia, placing the client at high risk for aspiration. Maintaining NPO status until a swallowing assessment is completed is the priority to prevent aspiration pneumonia, which is a life-threatening complication.

D. Perform range-of-motion exercises to the client's extremities: Range-of-motion exercises prevent contractures and maintain mobility. While important, this intervention is secondary to ensuring the client’s airway safety and preventing aspiration.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. An assistive personnel can evaluate a client's response to medication: Assistive personnel do not have the education or licensure to evaluate medication effects. They can perform delegated tasks such as vital signs or basic care, but assessment and evaluation of clinical responses remain within the RN’s scope of practice.

B. An RN can initiate the plan of care for a client on admission: Registered nurses are responsible for performing assessments, identifying nursing diagnoses, and developing an individualized plan of care upon admission. This is a core component of the RN’s legal scope of practice and requires professional judgment.

C. An RN can delegate blood administration to a licensed practical nurse: Blood administration is a high-risk procedure that generally cannot be delegated to an LPN in many states due to its complexity and potential for adverse reactions. The RN retains responsibility for administration and monitoring.

D. A licensed practical nurse can provide initial discharge instructions: Providing initial discharge instructions requires comprehensive assessment, education, and evaluation, which are within the RN’s scope of practice. LPNs may reinforce education but cannot independently provide initial instructions.

A. Severe hypertension B. Narrowed pulse pressure C. Diastolic murmur D. Increased heart rate

Correct Answer is A

Explanation

A. Severe hypertension: Cushing’s triad is characterized by increased systolic blood pressure with widening pulse pressure as a compensatory response to maintain cerebral perfusion during increased intracranial pressure. Severe hypertension is a hallmark finding.

B. Narrowed pulse pressure: In Cushing’s triad, the pulse pressure is typically widened, not narrowed, due to elevated systolic pressure and relatively lower diastolic pressure. Narrowed pulse pressure does not reflect the classic pattern associated with increased ICP.

C. Diastolic murmur: A diastolic murmur is a cardiac finding unrelated to increased intracranial pressure and is not a component of Cushing’s triad. It does not provide information about cerebral perfusion or ICP.

D. Increased heart rate: Cushing’s triad involves bradycardia rather than tachycardia, as part of the body’s compensatory response to elevated ICP. An increased heart rate is inconsistent with this classic presentation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is facilitating a seminar for newly licensed registered nurses. The focus of the seminar is to assist the nurses in understanding their legal scope of practice. Which of the following information should the nurse manager include in the seminar?

Correct Answer is B

Explanation

A nurse is assessing a client who is experiencing Cushing's triad due to increased intracranial pressure. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 32 weeks of gestation and has a history of cardiac disease. In which of the following positions should the nurse place the client to promote optimal cardiac output?

A nurse is caring for a client who wants to leave the facility against medical advice. In an attempt to prevent the client from leaving, an assistive personnel (AP) has hidden the client's car keys. Which of the following torts is the AP committing by hiding the client's car keys?

A nurse is providing teaching to a group of clients about contraceptive methods. Which of the following should the nurse include?

A nurse is assessing a client who is 24 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

A nurse is providing discharge teaching about postpartum contraception for a client who is breastfeeding and wishes to begin using contraceptive immediately. Which of the following methods should the nurse discuss with the client?

A nurse is providing teaching to a client who has a new prescription for lorazepam. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider?