A nurse is caring for a client.
A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Assist the client to the bathroom.
Initiate seizure precautions.
Record GCS every 15 min for the first 4 hr.
Elevate the head of the bed
Keep the client's head in midline position
Encourage the client to cough
Decrease oxygen to 1.5L/min via nasal cannula
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}
Rationale
• Assist the client to the bathroom.
• Non-essential: The client’s current condition indicates severe changes, including a significant drop in consciousness and worsening vital signs. Immediate priorities involve stabilization and monitoring rather than assisting with bathroom needs.
• Initiate seizure precautions.
• Anticipated: The client’s deteriorating condition, including restlessness, agitation, and decreased level of consciousness, increases the risk of seizures. Initiating seizure precautions is appropriate to ensure safety.
• Record GCS every 15 min for the first 4 hr.
• Anticipated: The Glasgow Coma Scale (GCS) score of 9 indicates a significant decrease in consciousness. Frequent monitoring of GCS is crucial to assess changes in neurological status and to guide further intervention.
• Elevate the head of the bed.
• Anticipated: Elevating the head of the bed can help with cerebral perfusion and decrease intracranial pressure. This is a common intervention for clients with neurological issues to improve comfort and safety.
• Keep the client's head in midline position.
• Anticipated: Maintaining a midline position helps ensure optimal cerebral perfusion and reduces the risk of complications. It is particularly important in clients with neurological changes.
• Encourage the client to cough.
• Non-essential: Given the client's current level of consciousness and agitation, encouraging coughing might not be appropriate and could cause further distress or complications.
• Decrease oxygen to 1.5L/min via nasal cannula.
• Contraindicated: The client’s oxygen saturation has dropped to 90% despite receiving 6 L/min of oxygen. Decreasing the oxygen flow could further impair oxygenation. The priority is to maintain or increase oxygen levels to ensure adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","F","G"]
Explanation
A. Temperature: The temperature remains stable and within normal limits. A postoperative temperature range of 36.3° C (97.3° F) to 36.4° C (97.5° F) is not indicative of infection or other complications at this time.
B. Heart rate: The heart rate has increased from 84/min to 104/min, indicating sinus tachycardia. This could be a compensatory response to decreased blood volume or another underlying issue, necessitating further assessment.
C. Skin findings: The skin findings are described as warm and dry, which is normal. No abnormalities are noted, so this does not require follow-up.
D. Respiratory rate: The respiratory rate has increased slightly to 24/min but is not significantly abnormal. This may not be a priority for follow-up unless other symptoms are present.
E. Oxygen saturation: The oxygen saturation is within normal limits (96% on room air), suggesting adequate oxygenation. No immediate concerns are evident based on this measurement.
F. Blood pressure: The blood pressure has dropped from 106/74 mm Hg to 88/54 mm Hg, indicating possible hypotension. This drop could signal hypovolemia or bleeding, requiring prompt follow-up to investigate the cause.
G. Urinary output: The urinary output of 110 mL over 6 hours is low, which might indicate dehydration or renal issues. Monitoring and addressing this finding are important to ensure adequate fluid balance and kidney function.
Correct Answer is B
Explanation
A. "I should take my supplement with an antacid to prevent an upset stomach": This is incorrect as antacids can interfere with the absorption of iron. Iron supplements should be taken on an empty stomach for better absorption.
B. "I should increase my fiber intake while taking this supplement": This is correct as increasing fiber can help manage constipation, a common side effect of iron supplementation.
C. "I should drink my liquid iron supplement undiluted": This is incorrect. Liquid iron supplements should be diluted to prevent staining of teeth and to improve tolerance.
D. "I should notify my doctor if my stools turn black": This is incorrect because black stools are a common side effect of iron supplementation and are generally not a cause for concern.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.