Which of the following actions is appropriate for managing a conscious patient with a suspected stroke?

Correct Answer: D

Rationale: Activating emergency medical services (EMS) for rapid transport to a stroke center is the most appropriate action for managing a conscious patient with a suspected stroke. Time is critical in stroke care, and receiving specialized treatment at a stroke center as soon as possible can significantly improve outcomes for stroke patients. EMS providers are trained to recognize the signs of stroke and can begin essential pre-hospital care measures while en route to the hospital. Administering aspirin immediately is not recommended without medical evaluation, as certain types of strokes (such as hemorrhagic strokes) can be worsened by aspirin. Placing the patient in a supine position may not be ideal, as maintaining an elevated position can help prevent aspiration in stroke patients. Encouraging the patient to eat and drink is not appropriate, as swallowing difficulties are common in stroke patients and can lead to aspiration pneumonia.

Correct Answer: B

Rationale: Mastitis is typically caused by bacterial infection, with predisposing factors including milk stasis (I) and nipple trauma (II). Milk stasis occurs when milk is not effectively removed from the breast, leading to a build-up that can block ducts and predispose to infection. Nipple trauma, such as cracks or damage, can provide entry points for bacteria to infect the breast tissue. Factors like using alcohol in cleaning nipples (III) and the baby's sitting position (IV) are not directly associated with the development of mastitis.

Correct Answer: B

Rationale: Cell-mediated immunity is a type of immune response that involves the activation of cytotoxic T cells and other immune cells to directly target and destroy infected or abnormal cells. It does not involve the production of antibodies, which are the primary component of humoral immunity. Antibodies are produced by B cells and are responsible for targeting extracellular pathogens such as bacteria and viruses. In contrast, cell-mediated immunity is more focused on targeting intracellular pathogens, cancerous cells, and other cells that have been compromised. So, production of antibodies is not usually associated with cell-mediated immunity.

Correct Answer: A

Rationale: The nurse should prioritize adjusting the irrigation flow rate based on the patient's urine output to prevent complications during continuous bladder irrigation (CBI). Proper adjustment of the irrigation flow rate helps maintain adequate bladder drainage while preventing bladder distention, clot formation, and potential irrigation fluid overload. Monitoring the patient's urine output and adjusting the flow rate accordingly ensures optimal functioning of the CBI system and enhances patient safety. This proactive approach minimizes the risk of complications and promotes effective postoperative care following urological surgery.

Correct Answer: D

Rationale: Before any procedure, it is crucial to ensure that you have the proper authorization and guidelines in place. By checking the physician's order and the patient care plan, you confirm that suctioning is indeed needed and that you follow the specific instructions for that patient. This step helps ensure patient safety and effective care delivery. Once you have verified this information, you can proceed with gathering equipment, performing hand hygiene, and assessing the patient's condition as necessary.