A nurse is assessing a client who is 4 hr postoperative following a craniotomy for the treatment of a benign brain tumor. Which of the following findings should the nurse identify as the priority?
15 mL of drainage in Hemovac
Periorbital ecchymosis
Nonreactive pupils
Hgb 11 g/dL
The Correct Answer is C
Choice A rationale:
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
Choice B rationale:
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
Choice C rationale:
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
Choice D rationale:
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Somatropin can affect glucose metabolism and may lead to hypoglycemia. Parents should be aware of this potential side effect and monitor their child's blood sugar levels.
Choice B rationale:
Somatropin is usually administered via injection, not under the tongue.
Choice C rationale:
Ringing in the ears is not a common side effect of somatropin.
Choice D rationale:
Monitoring height monthly is important, but explaining the potential for hypoglycemia is more relevant to the immediate safety of the child.
Correct Answer is C
Explanation
Choice A rationale:
Shaking the auto-injector is not recommended as it could disrupt the medication's effectiveness. Epinephrine auto-injectors contain two separate components that need to be mixed upon injection.
Choice B rationale:
Massaging the injection site after using the auto-injector can actually help disperse the medication and promote absorption and reduce pain and swelling.
Choice C rationale:
Injecting the medication into the top of the thigh is the correct administration site and technique for an epinephrine auto-injector. It's a large muscle area that allows for rapid absorption.
Choice D rationale:
Epinephrine auto-injectors should not be refrigerated, as extreme temperatures can affect their functionality. The client should store the device at room temperature away from light and heat sources.
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