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
Explanation
A. Orthopnea: This is more commonly associated with left-sided heart failure, where fluid accumulation in the lungs causes difficulty breathing when lying flat.
B. Lower-extremity edema: This is correct as right-sided heart failure often leads to fluid retention in the body, resulting in swelling of the lower extremities.
C. Clammy skin: This is not a typical finding specific to right-sided heart failure and may be seen in other conditions or complications.
D. Pink, frothy sputum: This is characteristic of left-sided heart failure and pulmonary edema, not right-sided heart failure.
Correct Answer is B
Explanation
A. Discourage drinking with a straw: Drinking with a straw is not typically discouraged for stomatitis and may actually help the client avoid contact with painful areas in the mouth.
B. Recommend consumption of cold items: This is correct as cold items can provide soothing relief for the inflamed mucous membranes in stomatitis, helping to reduce discomfort.
C. Provide an alcohol-based mouthwash: Alcohol-based mouthwashes can irritate the mucous membranes further and should be avoided. Non-alcoholic, soothing mouthwashes or saline rinses are preferred.
D. Minimize the use of gravies and sauces: While gravies and sauces can be irritating due to their acidity or spiciness, the primary recommendation is to focus on soothing and non-irritating foods and oral care practices.
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