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.
Potential Prescription: Anticipated /Nonessential /Contraindicated
Encourage the client to cough.
Keep the client's head in a midline position.
Elevate the head of the bed.
Assist the client to the bathroom.
Initiate seizure precautions.
Decrease oxygen to 1.5 L/min via nasal cannula.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}
A) Coughing is not directly related to the client's condition as described in the scenario.
B) Keeping the client's head in a midline position is anticipated to maintain an open airway and prevent further complications, particularly after a cerebrovascular accident.
C) Elevating the head of the bed is anticipated as it can help improve respiratory function and reduce intracranial pressure, which is beneficial given the client's history of cerebrovascular accident and current restlessness and agitation.
D) Assisting the client to the bathroom is contraindicated due to the client's current unresponsiveness and risk of falls; a bedpan or catheter may be more appropriate.
E) Initiating seizure precautions is anticipated because the client's Glasgow Coma Scale score indicates a decreased level of consciousness, which could predispose them to seizures, especially with a history of cerebrovascular accident.
F) Decreasing oxygen to 1.5 L/min via nasal cannula is contraindicated given the client's decreased oxygen saturation levels; instead, the nurse should anticipate the need to maintain or increase oxygen to ensure adequate tissue perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary risk associated with the observations noted.
B) A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection. Additionally, if the urinary catheter bag is not positioned below the level of the bladder, urine can reflux back into the bladder, which also increases the risk of infection.
C) Neurogenic bladder is a condition typically associated with nerve damage, not directly related to the position of the catheter bag or kinked tubing.
D) Phlebitis is inflammation of a vein, which would not be directly caused by the issues noted with the urinary catheter.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}
Explanation
A) Metoprolol is a beta-blocker that can help reduce heart rate and blood pressure, which is beneficial in cases of chest pain and irregular tachycardia.
B) Oxygen at 2 L/min via nasal cannula is anticipated because the client's oxygen saturation is below normal, indicating they may benefit from supplemental oxygen.
C) Drawing electrolytes along with Hgb and Hct is anticipated as it is important to monitor these levels due to the client's symptoms and history of hypertension and diabetes.
D) Morphine is anticipated because the client reports pain, and morphine can provide pain relief and reduce the workload on the heart.
E) Nitroglycerin is a standard treatment for chest pain due to its vasodilating effects, which can improve blood flow to the heart.
F) Obtaining daily weight is nonessential at this moment because it does not directly address the acute symptoms the client is experiencing.
G) Atropine is contraindicated as the client's heart rate is tachycardic, not bradycardic, and atropine is used to increase heart rate.
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