The nurse is caring for a patient recently admitted with a stroke. The patient is experiencing nausea and begins to vomit. Which of the following actions should the nurse take first?

Assist the patient to turn to her side.

Give an antiemetic as ordered.

Perform a test for blood on the emesis.

Call for an aide to get suction set up.

Answer and Explanation

The Correct Answer is A

A. Assist the patient to turn to her side: This is the priority action to prevent aspiration of vomitus, which can be a serious complication for stroke patients who may have impaired swallowing and a reduced gag reflex.
B. Give an antiemetic as ordered: While important, administering an antiemetic should come after ensuring the patient’s safety and preventing aspiration.
C. Perform a test for blood on the emesis: This is not the immediate priority. Preventing aspiration is the first concern.
D. Call for an aide to get suction set up: Suction may be necessary if the patient is at risk of aspiration, but the first step is to turn the patient to prevent choking and aspiration.

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Correct Answer is ["A","B","E"]

Explanation

A. "It is caused by a tumor of the adrenal gland.": This statement is incorrect as a tumor of the adrenal gland (like a pheochromocytoma) would cause secondary hypertension, not primary hypertension, which has no identifiable cause.
B. "The cause can be identified with magnetic resonance imaging.": Primary hypertension does not have a specific identifiable cause, and imaging like MRI cannot pinpoint a cause for it. This statement indicates a misunderstanding.
C. "The cause is unknown.": This statement is correct for primary hypertension, as it is characterized by having no identifiable underlying cause.
D. "There are no tests to identify the cause.": This is correct for primary hypertension since it has no specific identifiable cause. The diagnosis is based on excluding other potential causes of secondary hypertension.
E. "An arteriogram will show why hypertension is occurring.": An arteriogram might identify blockages or other issues in the arteries, but it will not show the cause of primary hypertension. This indicates a need for further teaching.

A. Monitoring for infection B. Monitoring circulatory status C. Validating proper mobility D. Checking discomfort level

Correct Answer is A

Explanation

Correct answer: A
A. Monitoring for infection: Infection is a significant risk with external fixation devices due to the presence of pins that penetrate the skin and soft tissues. Monitoring for signs of infection, such as redness, swelling, discharge, or increased pain, is crucial.
B. Monitoring circulatory status: While circulatory status is important, especially in cases of limb injury or immobilization, it is not the most immediate concern compared to the risk of infection from the external fixation device.
C. Validating proper mobility: Ensuring proper mobility is important, but it is secondary to the prevention and detection of infection. Mobility assessments can be done after confirming that there are no infections or complications.
D. Checking discomfort level: While assessing discomfort is important for pain management and comfort, it is not as critical as monitoring for infection, which can lead to severe complications if not addressed promptly.

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The nurse is caring for a patient recently admitted with a stroke. The patient is experiencing nausea and begins to vomit. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides teaching for a newly diagnosed patient with primary hypertension. Which of the following patient statements about the cause of primary hypertension would indicate the need for further teaching? Select all that apply

Correct Answer is ["A","B","E"]

Explanation

The nurse is preparing for a home visit to a patient with an external fixation device of the lower extremity. What priority care is anticipated?

Correct Answer is A

Explanation

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The nurse is caring for a patient with an external fixation device. Which of the following actions should the nurse implement? Select all that apply.

The nurse is caring for a group of patients. Which patient is the priority?

Which tests can be used to assist in diagnosing a patient with peripheral arterial disease? Select all that apply. (Select All that Apply.)