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) Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B) Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C) Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D) Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.
Correct Answer is C
Explanation
A) Increasing the ventilator flow rate may not address the cause of the low-pressure alarm and could potentially worsen the situation.
B) Emptying water from the ventilator tubing is not typically necessary when the low-pressure alarm sounds.
C) Evaluating the client for a cuff leak is essential because a leak in the endotracheal tube cuff can cause the low-pressure alarm to sound.
D) Suctioning the client's airway is not indicated unless there are signs of airway obstruction or secretions.
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