Nokea
The immediate nursing care to be provided to a patient presenting with a suspected ischaemic stroke include:
- A. Position on left lateral side, insert nasogastric tube, conduct an ECG and insert an IV line
- B. Primary/Secondary survey, give analgesia, 4th hourly neuro obs and vital signs, maintain oral intake
- C. Primary/Secondary survey, 4th hourly neuro obs and vital signs, monitor BGL and maintain nil by mouth
- D. 4th hourly neuro obs and vital signs, monitor BGL, insert an IV line and reduce intracranial pressure by positioning and reduced stimulation
Correct Answer: C
Rationale: Stroke hits fast surveys spot deficits, neuro obs track brain, vitals catch crashes, BGL rules out mimics, and nil by mouth preps for scans or clots, a tight first step. Lateral's for airways, not here; analgesia's late; IVs and ICP control follow. Nurses nail this, racing for tPA windows, a chronic precursor's acute kickoff.
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An oncology nurse is caring for a patient who has developed erythema following radiation therapy. What should the nurse instruct the patient to do?
- A. Periodically apply ice to the area
- B. Keep the area cleanly shaven
- C. Apply petroleum jelly to the affected area
- D. Avoid using soap on the treatment area
Correct Answer: D
Rationale: Radiation erythema red, raw skin needs gentle care to dodge worsening. Soap dries and irritates, stripping fragile skin and upping infection risk, so skipping it's key. Ice or heat can burn or blister radiated tissue, already thin and sensitive. Shaving scrapes it raw; petroleum jelly traps moisture, breeding bacteria. Nurses teach this to protect the site, pushing mild cleansers (if needed) and air exposure, standard in oncology to heal radiation burns without sparking new problems.
Which of the following assessment findings is a priority during blood transfusion?
- A. Chest pain
- B. Fatigue
- C. Joint pain
- D. Headache
Correct Answer: A
Rationale: Blood transfusions carry risks like acute reactions chest pain screams potential hemolytic or allergic response, a life-threatening emergency demanding immediate halt and intervention, prioritizing airway and circulation per ABCs. Fatigue is common, reflecting anemia's baseline, not an acute flag. Joint pain or headaches might hint at milder issues transfusion overload or tension but lack chest pain's urgency. Swift recognition of chest pain prevents escalation to shock or respiratory failure, a nurse's critical duty in transfusion safety, outranking less specific symptoms in this high-stakes scenario.
A client states that their legs have pain with walking that decreases with rest. The nurse observes absence of hair on the client's lower extremities and the client has a thread, weakened posterior tibial pulse. What would be the best position to have the client's legs?
- A. Elevated above the heart
- B. Slightly bent with three pillows under the knees
- C. Crossed at the knee
- D. Hanging down
Correct Answer: D
Rationale: PAD's claudication pain with walking, eased by rest plus hairless legs and weak pulses cry ischemia. Hanging legs down boosts gravity-fed flow, easing pain, the best position here. Elevation cuts supply, worsening it. Bending or crossing risks pressure. Nurses dangle limbs, enhancing perfusion, a practical fix in this arterial crunch.
The suture material which poses the highest risk of infection is
- A. Vicryl
- B. Chromic gut
- C. Silk
- D. Prolene
Correct Answer: C
Rationale: Silk braided, bacteria's nest tops infection risk, not Vicryl, gut's absorb, or slick Prolene, nylon. Nurses stitch this chronic trap warily.
You are caring for a patient with esophageal cancer. Which task could be delegated to the nursing assistant?
- A. Assist the patient with oral hygiene
- B. Observe the patient's response to feedings
- C. Facilitate expression of grief or anxiety
- D. Initiate daily weights
Correct Answer: A
Rationale: Delegating tasks in nursing hinges on scope of practice. Assisting with oral hygiene is a basic care activity nursing assistants are trained to perform, supporting hygiene needs in esophageal cancer patients who may struggle with swallowing. Observing responses to feedings requires clinical judgment to assess tolerance or complications, a nurse's responsibility. Facilitating emotional expression involves therapeutic communication skills beyond an assistant's training, critical for addressing cancer-related distress. Initiating daily weights implies deciding when to start, requiring understanding of fluid status assistants can weigh patients but not initiate the process independently. Oral hygiene delegation optimizes care efficiency, aligns with assistants' capabilities, and frees nurses for higher-level assessments, ensuring safe, effective management of this patient's complex needs.