The nurse is caring for a client who reports a sudden, severe facial numbness. The nurse observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left.

The client denies a recent history of headaches or trauma.

Which intervention should the nurse perform immediately?

Maintain elevated positioning of the dependent joints on the affected side.

Verify prescribed laboratory tests include prothrombin time and platelet count.

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

Administer aspirin to prevent further clot formation and platelet clumping.

Answer and Explanation

The Correct Answer is C

Choice A rationale
While maintaining elevated positioning of the dependent joints on the affected side can be helpful in certain conditions such as edema or injury, it is not the immediate intervention needed for a client presenting with sudden, severe facial numbness, uneven smile with facial droop to the right side, and a hand grasp strength that is weaker on the right than the left.
Choice B rationale
Verifying prescribed laboratory tests including prothrombin time and platelet count is important in assessing the client’s coagulation status. However, it is not the immediate intervention needed in this situation.
Choice C rationale
The client’s symptoms are suggestive of a stroke. In such cases, immediate medical intervention is crucial. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an appropriate immediate intervention.
Choice D rationale
Administering aspirin can be beneficial in preventing further clot formation and platelet clumping in clients at risk of a stroke. However, it is not the immediate intervention needed in this situation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale
Exclusively consuming lactose-free dairy products is not a specific characteristic of the DASH diet. While the DASH diet recommends low-fat or fat-free dairy products, it does not specifically require them to be lactose-free.
Choice B rationale
Meticulously cleaning and peeling all fresh fruits and vegetables is a good practice for food safety, but it is not specific to the DASH diet.
Choice C rationale
Enjoying fat-free yogurt as an occasional snack aligns with the DASH diet’s emphasis on low-fat dairy products.
Choice D rationale
Eliminating grains from the diet is not recommended in the DASH diet. On the contrary, the DASH diet encourages the consumption of whole grains.

A. Activity level of bowel sounds. B. Level and amount of physical activity. C. Eating patterns of dietary intake. D. Color and consistency of feces.

Correct Answer is C

Explanation

Choice A rationale
While the activity level of bowel sounds can provide information about the functioning of the gastrointestinal system, it is not the most important data to manage the patient’s pain from chronic pancreatitis.
Choice B rationale
The level and amount of physical activity can affect the patient’s pain level, but it is not the most crucial data for managing pain in chronic pancreatitis.
Choice C rationale
Eating patterns of dietary intake are the most important data to manage the patient’s pain. In chronic pancreatitis, certain foods can exacerbate the pain. Understanding the patient’s dietary habits can help in providing appropriate dietary modifications.
Choice D rationale
The color and consistency of feces can provide information about the patient’s digestive health, but it is not the most important data to manage the patient’s pain from chronic pancreatitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient’s understanding of the DASH (Dietary Approaches to Stop Hypertension) diet. Which patient behavior suggests adherence to this diet?

Correct Answer is C

Explanation

The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient’s pain?

Correct Answer is C

Explanation

An elderly patient is admitted with an acute onset of diverticulitis, and intravenous antibiotic therapy is started. What should the nurse do next?

An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient’s response to treatment? (Select all that apply.)

A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse’s priority intervention?

A patient in the operating room has been administered succinylcholine and is now experiencing muscle rigidity and an extremely high temperature. What should the nurse do next?