A nurse is assisting with the care of a client who has suspected meningitis and a decrease level of consciousness. Which of the following actions should the nurse take?
Prepare the client for liver biopsy
Put the client in a protective environment
Position the client dorsal recumbent
Place the client on NPO status
The Correct Answer is D
D. The correct action would be to place the client on NPO (Nothing by Mouth) status, option D. This is because a decreased level of consciousness can increase the risk of aspiration.
A. Liver biopsy is not indicated for suspected meningitis with a decreased level of consciousness. Liver biopsy is a procedure used to obtain a sample of liver tissue for diagnostic purposes, typically to evaluate liver function or diagnose liver diseases.
B. A protective environment (option B) is more related to immunocompromised patients. In the case of decreased level of consciousness, preventing aspiration is key.
C. Dorsal recumbent position refers to lying on the back with the knees flexed. While this position may be suitable for certain medical procedures or examinations, it is not specifically indicated for a client with suspected meningitis and a decreased level of consciousness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Pancreatic enzymes should not be mixed with acidic foods or liquids, as this can reduce their effectiveness. Instead, the enzymes should be sprinkled on soft, non-acidic foods or swallowed whole with a glass of water or juice.
A. Pancreatic enzymes are generally safe and well-tolerated when taken as prescribed but they can cause side effects in some individuals. Common side effects may include abdominal pain, diarrhea, constipation, nausea, and bloating.
B. Pancreatic enzymes help individuals with cystic fibrosis digest fat, as well as proteins and carbohydrates. In cystic fibrosis, the pancreas does not produce enough digestive enzymes, leading to malabsorption of nutrients, particularly fat. Supplemental pancreatic enzymes help compensate for this deficiency and improve nutrient absorption.
C. Pancreatic enzymes are typically taken with meals or snacks to aid in digestion. However, if the child is consuming a small meal or snack that contains minimal fat, the enzymes may not be necessary. It's important for the mother to follow the healthcare provider's instructions regarding when and how to administer the enzymes.
Correct Answer is D
Explanation
D. An oxygen saturation level of 85% is significantly below the normal range and indicates hypoxemia (low blood oxygen levels). This finding is concerning, especially in a child with cystic fibrosis, which can lead to respiratory complications such as airway obstruction, infection, or mucus plugging.
A. A blood glucose level of 140 mg/dL is within the normal range for children, so this finding would not typically require immediate reporting to the provider.
B. A serum sodium level of 156 mEq/L is significantly elevated and above the normal range. However, hypoxia is the priority.
C. A red blood cell (RBC) count of 3.2 million/µL falls within the normal range for children, so this finding would not typically require immediate reporting to the provider.
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