The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Obtain an electrocardiogram (ECG) exam

Obtain intravenous access

Administer 2 L of oxygen per nasal cannula

Obtain a rectal temperature

Answer and Explanation

The Correct Answer is C

A. Obtain an electrocardiogram (ECG) exam: While an ECG is important to assess cardiac status, it is not the immediate priority compared to addressing the low oxygen saturation.
B. Obtain intravenous access: IV access is important for administering medications and fluids but does not take precedence over addressing hypoxia.
C. Administer 2 L of oxygen per nasal cannula: This is correct. The priority is to improve oxygenation since hypoxia can exacerbate neurological damage in a stroke patient. An SpO2 of 88% is low and requires immediate correction to prevent further complications.
D. Obtain a rectal temperature: Temperature assessment is not as urgent as addressing the immediate need for oxygen to improve SpO2 levels.

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

Explanation

A. Paresthesia: Numbness or tingling sensations (paresthesia) can occur due to decreased blood supply and nerve function.
B. Pruritus: Itching (pruritus) is not typically associated with arterial occlusion. It is more often related to skin conditions or allergies.
C. Pain: Pain is a hallmark symptom of arterial occlusion, often described as severe and sudden, due to tissue ischemia.
D. Pallor: Affected limbs or areas may appear pale (pallor) because of reduced blood flow.
E. Palpitations: Palpitations are not a direct symptom of arterial occlusion. They are more related to cardiac conditions.

A. I will be sure to avoid potassium while taking this medication. B. I should take the medication in the morning so I am not up all night going to the bathroom. C. I need to be sure to take this pill on an empty stomach. D. If my blood pressure is really high, I will take a second dose.

Correct Answer is B

Explanation

A. I will be sure to avoid potassium while taking this medication.: Thiazide diuretics can cause potassium loss, so patients are often advised to monitor their potassium levels and may need to increase their intake, not avoid it.
B. I should take the medication in the morning so I am not up all night going to the bathroom.: This is correct. Taking diuretics in the morning helps prevent nocturia (frequent urination at night), which can disrupt sleep.
C. I need to be sure to take this pill on an empty stomach.: Thiazide-like diuretics do not require an empty stomach for effectiveness; they can be taken with or without food.
D. If my blood pressure is really high, I will take a second dose.: This is incorrect and potentially dangerous. Medication dosing should be followed as prescribed, and adjustments should only be made by a healthcare provider.

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The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are clinical manifestations of arterial occlusion? Select all that apply.

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

Explanation

The nurse is teaching a patient about a thiazide-like diuretic. Which statement made by the patient indicates an understanding of the teaching?

Correct Answer is B

Explanation

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