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.

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Correct Answer is B

Explanation

Choice A rationale
Similar to, while spicy foods can irritate the urinary tract, they do not have a direct impact on the care and management of an indwelling urinary catheter after a TURP3.
Choice B rationale
As in, drinking 3 liters of water each day is important as it helps flush the bladder and reduce the risk of urinary tract infections, which are a common complication after a TURP3.
Choice C rationale
As in, clamping the catheter is not typically recommended as it can lead to urinary retention and increase the risk of urinary tract infections.
Choice D rationale
As in, avoiding driving for 2 weeks is a general recommendation after any major surgery to allow the body time to heal, but it does not directly relate to the care of an indwelling urinary catheter.

A. Computerized tomography (CT) of the chest. B. Arterial blood gases (ABG). C. Sputum culture and sensitivity. D. Blood cultures.

Correct Answer is C

Explanation

Choice A rationale
A CT scan of the chest can be performed to detect the severity of infection in pneumonia. However, it is not typically the first diagnostic test prescribed. It is usually recommended if the pneumonia isn’t clearing as quickly as expected.
Choice B rationale
Arterial blood gases (ABG) can be used to measure the oxygen level in your blood. Pneumonia can prevent your lungs from moving enough oxygen into your bloodstream. However, ABG is not typically the first diagnostic test prescribed for pneumonia.
Choice C rationale
A sputum culture test is often used to confirm the cause of infection in pneumonia. This test involves taking a sample of fluid from your lungs (sputum) after a deep cough and analyzing it to help pinpoint the cause of the infection.
Choice D rationale
Blood cultures can identify the germ causing your pneumonia and also show whether a bacterial infection has spread to your blood. However, they are not typically the first diagnostic test prescribed for pneumonia.

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Naxlex Comprehensive Predictor Exams

After a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. What is the most important instruction for the nurse to include in the discharge teaching plan?

Correct Answer is B

Explanation

The healthcare provider prescribes diagnostic tests for a patient whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse prepare the patient for?

Correct Answer is C

Explanation

A client receives a prescription for 1 liter of lactated Ringer’s intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?

A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?

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.)

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

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?

A client who was recently diagnosed with Raynaud’s disease is concerned about pain management. Which nursing instruction should the nurse provide?

A patient with gouty arthritis is experiencing tenderness and swelling in the right ankle and big toe. The nurse notes that the inflammation extends above the ankle area. The patient has been prescribed colchicine and indomethacin. What should the nurse include in the discharge teaching?