A child with a brain tumor has a decreased respiratory hate and is less responsive to verbal commands than he was when the nurses assessed the client the previous hour. What should the nurse do next?
Raise the head of the bed
Notify the health care provider (HCP)
Obtain an oximeter reading
Implement seizure precautions
The Correct Answer is B
A. Raising the head of the bed may help with respiratory effort but does not address the underlying issue of decreased responsiveness. Immediate assessment and intervention are necessary.
B. Notifying the healthcare provider is critical as the child’s decreased responsiveness and respiratory rate indicate a potential deterioration in condition that requires prompt medical evaluation.
C. While obtaining an oximeter reading can provide useful information about oxygenation, the priority is to notify the HCP about the change in the child's neurological status.
D. Implementing seizure precautions is important for a child with a brain tumor, but the immediate concern is the change in responsiveness, necessitating HCP notification first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering iron supplements at mealtimes can decrease absorption, making it less effective.
B. Giving ferrous sulfate with milk can inhibit the absorption of iron due to the calcium content.
C. Administering iron at bedtime is not recommended because it can cause gastrointestinal upset and may interfere with sleep.
D. Giving ferrous sulfate with orange juice enhances the absorption of iron due to the vitamin C content, which is beneficial for children with iron deficiency anemia.
Correct Answer is D
Explanation
A. Removing nits with a fine-tooth comb is a crucial step in managing head lice to prevent re-infestation.
B. Washing bedding and clothing in hot water or sealing non-washable items helps eliminate lice and nits from the environment.
C. Soaking combs and brushes in hot water with shampoo helps ensure that any lice or nits on the grooming tools are eradicated.
D. All of the provided options are appropriate measures for managing pediculosis capitis effectively.
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