A nurse is caring for a client.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Store the medication in the refrigerator: Diltiazem sustained-release tablets do not need to be refrigerated; they should be stored at room temperature, away from moisture and heat.
B. Take the medication at mealtime: It is not necessary to take diltiazem with food unless specifically advised by a healthcare provider. Generally, it can be taken with or without food.
C. Drink grapefruit juice with the medication: Grapefruit juice should be avoided with diltiazem as it can increase the risk of adverse effects by altering the metabolism of the drug.
D. Swallow the medication whole: This is correct as sustained-release tablets should not be chewed or crushed. They are designed to release the medication slowly over time, which can be disrupted if the tablet is altered.

A. Ammonia 55 mcg/dL (10 to 80 mcg/dL) B. Platelets 60,000/mm³ (150,000 to 400,000/mm³) C. Aspartate aminotransferase 34 units/L (0 to 34 units/L) D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)

Correct Answer is B

Explanation

A. Ammonia 55 mcg/dL (10 to 80 mcg/dL): This value is within the normal range and does not indicate an immediate concern for a liver biopsy.
B. Platelets 60,000/mm³ (150,000 to 400,000/mm³): This value is significantly below the normal range and indicates thrombocytopenia, which increases the risk of bleeding during a liver biopsy and should be reported to the provider.
C. Aspartate aminotransferase 34 units/L (0 to 34 units/L): This value is on the upper limit of normal and generally does not require reporting unless there are other clinical concerns.
D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL): This value is at the upper limit of normal and does not require reporting unless there are additional symptoms or concerns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is taking diltiazem sustained-release tablets for hypertension. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?

Correct Answer is B

Explanation

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