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 B

Explanation

a. Overusing a muscle while jogging: Overuse injuries are more commonly associated with strains, not sprains. Strains involve the muscles or tendons.

b. Twisting a ligament while walking: This is an example of a mechanism that can lead to a sprain. A sprain involves the stretching or tearing of ligaments, which connect bone to bone.

c. Impact injury on a joint from a fall: This is more likely to result in a sprain, as it can cause damage to ligaments.

d. Crush injury to a bone from blunt trauma: This type of injury is more likely to affect bones rather than ligaments or tendons, and it would not be considered a sprain or strain.

A. Begin oxygen therapy. B. Start an IV infusion of lactated Ringer’s. C. Initiate cardiac monitoring. D. Administer IV morphine.

Correct Answer is A

Explanation

a. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.

b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.

c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.

d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.

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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

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Correct Answer is A

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