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 A

Explanation

Choice A Rationale: The correct method for cleansing the area before collecting a midstream urine specimen is to wipe from front to back, not back-and-forth. This is to avoid contamination of the specimen with bacteria from the anal area. The towelette should be used in a single stroke and then discarded to ensure cleanliness.

Choice B Rationale: Using the nondominant hand to spread the labia is a standard practice that allows the dominant hand to manipulate the collection container. This technique helps to prevent contamination of the specimen by keeping the container away from the body and ensuring a clean catch.

Choice C Rationale: It is important to start the flow of urine before collecting the specimen to ensure that the 'midstream' urine is captured. This helps to flush out any bacteria that may be present at the opening of the urethra, reducing the risk of contaminating the sample.

Choice D Rationale: The specimen container should be removed from the stream before stopping the flow of urine to avoid contamination. The initial and final parts of the urine stream can carry bacteria from the urethra and skin, so only the midstream should be collected in the container.

A. “I will notify my provider before taking any other medications.” B. “I have made an appointment to see my dentist next week.” C. “I will take this medication with meals.” D. "I'll be glad when my seizures stop so I can quit taking this medicine."

Correct Answer is D

Explanation

A. “I will notify my provider before taking any other medications.” - This statement reflects an understanding of the need to check for potential interactions with other medications, which is an appropriate response.

B. “I have made an appointment to see my dentist next week.” - Dental care is important, and

scheduling an appointment with the dentist is a responsible action. However, it does not indicate a misunderstanding about the medication.

C. “I will take this medication with meals.” - Taking phenytoin with meals is a correct instruction as it can help reduce gastrointestinal side effects.

D. "I'll be glad when my seizures stop so I can quit taking this medicine." - This statement

indicates a misunderstanding about the chronic nature of anti-seizure medications. The client needs further education on the importance of continuing the medication even if seizures stop.

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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

Naxlex Comprehensive Predictor Exams

charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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