Nokea
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?
- A. Maintain elevated positioning of the dependent joints on the affected side.
- B. Verify prescribed laboratory tests include prothrombin time and platelet count.
- C. Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
- D. Administer aspirin to prevent further clot formation and platelet clumping.
Correct Answer: C
Rationale: Symptoms suggestive of a stroke require immediate initiation of IV access and evaluation for fibrinolytic therapy to restore cerebral blood flow.
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A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication does the nurse anticipate being prescribed by the healthcare provider?
- A. Morphine.
- B. Oxycodone.
- C. Hydromorphone.
- D. Fentanyl.
Correct Answer: A
Rationale: Morphine is typically prescribed for myocardial infarction symptoms to relieve pain and reduce cardiac workload.
A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?
- A. Document the findings.
- B. Elevate the extremity.
- C. Apply gentle pressure.
- D. Assess the client's temperature.
Correct Answer: A
Rationale: A bruit indicates a patent AV graft, a normal finding that should be documented.
A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?
- A. Painful areas should be rubbed gently until the pain subsides.
- B. Wearing gloves when handling cold items guards against painful spasms.
- C. Return appointments will be needed for IV pain medication.
- D. Enrolling in a pain clinic can provide pain relief alternatives.
Correct Answer: B
Rationale: Wearing gloves prevents cold-induced spasms, reducing pain in Raynaud's disease.
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Explain the need to limit intake of oral fluids to reduce client discomfort.
- B. Teach the client techniques for performing intermittent catheterization.
- C. Remind the client to practice pelvic floor (Kegel) exercises regularly.
- D. Provide a bedside commode for immediate use in the client's room.
Correct Answer: B
Rationale: Intermittent catheterization manages urinary retention effectively in multiple sclerosis, maintaining bladder health.
The parent of an adolescent tells the clinic nurse, 'My child has athlete's foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.' Which instruction should the nurse provide?
- A. Antibiotics take two weeks to become effective against infections such as athlete's foot.
- B. Continue using the ointment for a full week, even after the symptoms disappear.
- C. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration.
- D. Stop using the ointment and encourage complete drying of feet and wearing clean socks.
Correct Answer: D
Rationale: Athlete's foot is fungal, not bacterial; stopping antibiotic ointment and keeping feet dry with clean socks aids treatment.