A nurse in the emergency room is assessing a patient who was brought in following a seizure. The nurse suspects the patient may have bacterial meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?
Assess the cranial nerves.
Decrease environmental stimuli.
Close the room.
Administer an antipyretic.
The Correct Answer is B
Choice A reason: Assessing the cranial nerves is important, but it is not the immediate next step after implementing droplet precautions for suspected bacterial meningitis.
Choice B reason: Decreasing environmental stimuli can help reduce the risk of seizures and is a supportive measure for a patient with suspected bacterial meningitis.
Choice C reason: Closing the room is part of implementing droplet precautions but is not an action that needs to be initiated by the nurse as it should already be in place.
Choice D reason: Administering an antipyretic may be necessary if the patient has a fever, but it is not the immediate next action after droplet precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Urine specific gravity measures the kidney's ability to concentrate urine. A normal range is typically 1.005–1.030. A value of 1.020 indicates adequate hydration and suggests that the patient is responding well to IV fluid therapy.
Choice B reason: Serum sodium levels reflect electrolyte balance. The normal range is 135–145 mEq/L. A level of 165 mEq/L is significantly elevated, indicating hypernatremia, which could be a sign of inadequate hydration and not a positive response to treatment.
Choice C reason: Hematocrit represents the proportion of blood volume occupied by red blood cells. Normal ranges are 38.3–48.6% for men and 35.5–44.9% for women. A hematocrit of 48% is at the upper limit of normal and does not specifically indicate the effectiveness of dehydration treatment.
Choice D reason: Blood urea nitrogen (BUN) levels can indicate renal function and hydration status. The normal range is 7–20 mg/dL. A BUN of 12 mg/dL is within the normal range and does not specifically reflect the patient's response to IV fluids for dehydration.
Correct Answer is B
Explanation
Choice A reason: Establishing short-term, realistic goals is important, but it should come after assessing the client's current knowledge. Goals should be tailored to the individual's needs and understanding.
Choice B reason: Assessing the client's current knowledge about managing diabetes is crucial as the first step. This allows the nurse to identify any gaps in understanding and to provide education that is specific to the client's needs.
Choice C reason: Providing access to a video about diabetes can be a useful educational tool, but it should not be the first action. The content of the video may not address the client's specific questions or misconceptions.
Choice D reason: Evaluating the effectiveness of the client's admission teaching plan is an ongoing process and should be done after initial education and interventions have been provided.
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