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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.

A.

Encourage the client to cough.

B.

Initiate seizure precautions.

C.

Elevate the head of the bed.

D.

Keep the client's head in a midline position.

E.

Decrease oxygen to 1.5 L/min via nasal cannula.

F.

Assist the client to the bathroom.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Rationale

Interpretation of Actions:

  • Encourage the client to cough:
    • Nonessential
      Encouraging the client to cough is not a priority in this situation. The client's neurological status is deteriorating, and the focus should be on managing intracranial pressure and ensuring airway patency rather than promoting coughing.
  • Initiate seizure precautions:
    • Anticipated
      Seizure precautions are appropriate due to the client's declining neurological status, as seizures can occur with increased intracranial pressure or other neurological changes.
  • Elevate the head of the bed:
    • Anticipated
      Elevating the head of the bed to 30 degrees promotes venous drainage and helps reduce intracranial pressure, which is critical given the client's symptoms.
  • Keep the client's head in a midline position:
    • Anticipated
      Maintaining a midline head position prevents obstruction of venous outflow and helps reduce intracranial pressure.
  • Decrease oxygen to 1.5 L/min via nasal cannula:
    • Contraindicated
      Reducing oxygen is inappropriate in this situation. The client's altered mental status and vomiting suggest potential hypoxia or increased intracranial pressure, requiring close monitoring of oxygenation rather than decreasing it.
  • Assist the client to the bathroom:
    • Contraindicated
      Assisting the client to the bathroom is unsafe due to their altered mental status, restlessness, and risk of falls or further neurological compromise. Instead, measures to prevent overexertion, such as using a bedpan, should be implemented.


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Related Questions

Correct Answer is A

Explanation

A. A capillary refill time of 6 seconds is considered abnormal and suggests poor circulation, which could indicate compromised blood flow to the extremity. This requires immediate intervention to assess for potential complications like compartment syndrome, which can occur with fractures and external fixators.

B. An oral temperature of 38.3° C (100.9° F) is slightly elevated but is not an immediate concern unless it persists or rises higher. A mild fever can be common after surgery but should be monitored for any signs of infection.

C. A closed-suction drain output of 100 mL is within the expected range and is not a cause for concern unless the drainage increases or becomes excessive.

D. A pain level of 7 on a scale of 0 to 10 is significant, but pain is common after surgery. The nurse should address pain management, but this is not an immediate priority compared to circulation concerns.

Correct Answer is A

Explanation

A. Keep soiled bed linens in the client's room: This is correct. During internal radiation (brachytherapy), items in contact with the client, including soiled linens, must remain in the room until radiation treatment is complete to prevent accidental radiation exposure to staff or other clients. Radiation safety protocols require limiting the spread of potentially contaminated materials.
B. Discard the radioactive device in the client's trash can: This is unsafe and violates strict radiation safety procedures. A dislodged device must be handled only with forceps and stored in a lead container until properly managed by radiation safety personnel.
C. Instruct visitors to remain 3 feet from the client: While distance is important, visitors should actually maintain at least 6 feet from the client and visits should be kept short, typically under 30 minutes.
D. Limit time for visitors to 2 hr per day: This exceeds the standard safety limit. The time spent by visitors in the room should be minimized—generally limited to 30 minutes or less per day—to reduce exposure to radiation.

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