A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the following actions should the nurse take?
Monitor the client for hypoglycemia.
Perform range-of-motion exercises once per shift
Place the client in high-Fowler's position.
Implement seizure precautions.
The Correct Answer is D
Rationale:
A. Monitor the client for hypoglycemia: Hypoglycemia is not a common complication of bacterial meningitis. More relevant concerns include increased intracranial pressure, fever, and potential neurological damage, rather than altered glucose metabolism.
B. Perform range-of-motion exercises once per shift: While maintaining mobility is important, this is not a priority during the acute phase of bacterial meningitis. The client may be photophobic, confused, or in too much discomfort for routine exercises early in treatment.
C. Place the client in high-Fowler's position: High-Fowler’s can increase discomfort and may worsen meningeal irritation. A more appropriate position is 30 degrees with head midline to promote venous drainage and reduce intracranial pressure.
D. Implement seizure precautions: Seizures are a potential complication of bacterial meningitis due to inflammation, increased intracranial pressure, and irritation of the cerebral cortex. Seizure precautions are a critical safety measure in the acute phase of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Change the drainage tubing every 48 hr: Closed wound drainage systems are designed to remain intact and sterile until removal. Routine replacement of tubing can introduce pathogens and is not recommended unless there is evidence of damage or contamination.
B. Observe for drainage flow through the tubing: Monitoring the flow and character of drainage ensures the system is functioning correctly and allows early detection of complications like blockage, dislodgment, or infection.
C. Remove the drain if output from the drain increases: An increase in drainage volume can signal active bleeding, infection, or poor wound healing. Instead of removing the drain, the nurse should notify the provider for further evaluation and guidance on next steps.
D. Irrigate the drain to maintain suction: Closed drainage systems like Jackson-Pratt or Hemovac are designed to maintain negative pressure without irrigation. Introducing fluid into the system can break the vacuum seal, reduce effectiveness, and increase the risk of infection.
Correct Answer is C
Explanation
Rationale:
A. Temperature 36.8° C (98° F): This temperature is within the normal range and does not suggest a current or impending infection. It indicates stable thermoregulation in the postoperative period.
B. White blood cell count 8,000/mm³ (5,000 to 10,000/mm³): This WBC count falls within the normal reference range and does not reflect infection or inflammation. No abnormal immune response is indicated by this result.
C. Body mass index of 32: A BMI over 30 is classified as obesity, which increases the risk of poor wound healing and surgical site infections. Excess adipose tissue can impair circulation, oxygenation, and immune response at the wound site.
D. Blood glucose 90 mg/dL (74 to 106 mg/dL): This is a normal fasting glucose level and does not contribute to infection risk. Well-controlled glucose levels are favorable for wound healing and immune function.
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