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.

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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B) Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C) Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D) Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.

A. Alert and orientated x4 B. Heart and lung sounds clear C. Client urinating 100 mL/hour D. Client is tolerating soft diet and oral fluids E. Bilateral pedal pulses 2+ F. Temperature 36.8° C (98.2° F) G. Pulse rate 84/min H. Respiratory rate 16/min I. Blood pressure 106/76 mm Hg J. Oxygen saturation 96% on room air

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

The client's condition shows signs of improvement as indicated by several findings. The blood glucose level has decreased from 468 mg/dL to 310 mg/dL, which, although still above the normal range, is a significant improvement. The pulse rate has normalized from 110/min to 84/min, and the blood pressure has improved from 96/65 mm Hg to 106/76 mm Hg, indicating better cardiovascular stability. The

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Naxlex Comprehensive Predictor Exams

A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

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