1. Answer: B. Pupil size and pupillary response
Kinking of the ventilator tubing
It is crucial to monitor the pupil size and pupillary
response to indicate changes around the cranial
nerves.
Option A: Cholesterol level is an assessment to be
addressed for long-term healthy lifestyle
rehabilitation.
Option C: Bowel sounds need to be assessed
because an ileus or constipation can develop, but is
not a priority in the first 24 hours.
Option D: An echocardiogram is not needed for the
client with a thrombotic stroke.
2. Answer: C. Dissolved emboli.
Thrombolytic therapy is used to dissolve emboli and
reestablish cerebral perfusion.
3. Answer: C. A blood pressure of 220/120 mmHg.
Uncontrolled hypertension is a risk factor for
hemorrhagic stroke, which is a ruptured blood
vessel in the cranium.
Option A: High blood glucose levels could
predispose a patient to ischemic stroke, but not
hemorrhagic.
Option B: Bruit in the carotid artery would
predispose a client to an embolic or ischemic
stroke.
Option D: Cancer is not a precursor to stroke.
4. Answer: A. Position the patient sitting up in bed
before you feed her.
Option A: Positioning the patient in a sitting
position decreases the risk of aspiration.
Option B: The nursing assistant is not trained to
assess gag or swallowing reflexes.
Option C: The patient should not be rushed during
feeding.
Option D: A patient who needs to be suctioned
between bites of food is not handling secretions
and is at risk for aspiration. This patient should be
assessed further before feeding. Focus:
Delegation/supervision
5. Answer: A.
Conditions that trigger the high-pressure alarm
include kinking of the ventilator tubing,
bronchospasm or pulmonary embolus, mucus
plugging, water in the tube, coughing or biting on
endotracheal tube, and the patient’s being out of
breathing rhythm with the ventilator. A
disconnected ventilator tube or an endotracheal
cuff leak would trigger the low pressure alarm.
Changing the oxygen concentration without
resetting the oxygen level alarm would trigger the
oxygen alarm.
6. Answer: A. Stridor
The nurse reports stridor to the physician
immediately. This is a high-pitched, coarse sound
that is heard with the stethoscope over the trachea.
Stridor indicates airway edema and places the client
at risk for airway obstruction. Options B, C, and D
are not signs that require immediate notification of
the physician.
7. Answer: C. 10 seconds
Hypoxemia can be caused by prolonged suctioning,
which stimulates the pacemaker cells in the heart. A
vasovagal response may occur, causing bradycardia.
The nurse must preoxygenate the client before
suctioning and limit the suctioning pass to 10
seconds.
8. Answer: C. Stop the procedure and reoxygenate
the client
During suctioning, the nurse should monitor the
client closely for side effects, including hypoxemia,
cardiac irregularities such as a decrease in heart
rate resulting from vagal stimulation, mucosal
trauma, hypotension, and paroxysmal coughing. If
side effects develop, especially cardiac
irregularities, the procedure is stopped and the
client is reoxygenated.
9. Answer: C. Tidal volume
Tidal volume refers to the volume of air inspired
and expired with a normal breath.
Total lung capacity is the maximal amount of air the
lungs and respiratory passages can hold after a
forced inspiration.
 Forced vital capacity is the vital capacity performed
with a maximally forced expiration.

Residual volume is the maximal amount of air left in

the lung after a maximal expiration.

10. Answer: B. Use of accessory muscles

The use of accessory muscles for respiration

indicates the client is having difficulty breathing.
Diaphragmatic and pursed-lip breathing are two
controlled breathing techniques that help the client
conserve energy.

I. GCS

Eye:
4-Spontaneous
3-To sound
2-To pressure
1-None

Verbal:
5-Orientated
4-Confused
3-Words
2-Sounds
1-None

Motor:
6-Obey commands
5-Localising pain
4-Normal flexion/Withdraws from pain
3-Abnormal (spastic) flexion, decorticate posture
2-Extensor (rigid) response, decerebrate posture
1-None

II. Pupils Equally Round and Reactive to Light and

Accomodation
III. A/C – Assist controlled
SIMV – Spontaneous Intermitted Mandatory
Ventilation
NSTEMI – Non ST elevated Myocardial
Infarction
NAC – N-acetylcysteine