A nurse is contributing to the plan of care for a client who had a craniotomy. Which of the following interventions should the nurse include in the plan?

Apply a warm cloth over the client's eyes.

Place the client in a supine position.

Maintain seizure precautions.

Obtain a prescription for an opioid medication for pain.

Answer and Explanation

The Correct Answer is C

a. Apply a warm cloth over the client's eyes: This intervention is not typically indicated for a client who had a craniotomy. It is important to monitor for signs of increased intracranial pressure, but a warm cloth over the eyes is not a standard intervention.

b. Place the client in a supine position: The position of the client after a craniotomy will depend on the surgeon's preference. It is important to follow specific postoperative positioning

instructions, which may or may not include supine positioning.

c. Maintain seizure precautions: Seizure precautions are crucial for clients who have had a craniotomy, as they are at an increased risk of seizures postoperatively.

d. Obtain a prescription for an opioid medication for pain: Pain management is important, but opioid medications may be carefully titrated due to the potential for respiratory depression and other side effects. It is not the primary intervention in the immediate postoperative period.

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Correct Answer is D

Explanation

a. Turn the client so the cast will dry on all sides: While ensuring the cast is dry is important, the first priority following a surgical procedure is to assess neurovascular status to detect any

complications.

b. Remove the window and view the incision: Removing the window may compromise the cast's integrity, and the priority is to assess neurovascular status before inspecting the incision.

c. Medicate the client for pain: Pain management is important, but assessing neurovascular status is the initial priority to ensure there are no complications affecting circulation.

d. Perform neurovascular checks of the affected extremity: Neurovascular checks are the priority to detect any signs of impaired circulation or nerve function.

A. Provide humidified oxygen. B. Prelubricate the suction catheter tip with sterile saline when suctioning the airway. C. Perform chest physiotherapy prior to suctioning. D. Hyperventilate the client with 100% oxygen before suctioning the airway.

Correct Answer is A

Explanation

a. Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thin

secretions in a client with a tracheostomy.

b. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.

c. Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.

d. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providing

humidified oxygen is a more appropriate approach.

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A nurse is contributing to the plan of care for a client who had a craniotomy. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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