A nurse is contributing to the plan of care for a newly admitted adolescent.
A nurse is contributing to the plan of care for a newly admitted adolescent. Which of the following interventions should the nurse include?
Suction the client's airway every 2 hr.
Maintain the client's head of the bed at 30°.
Keep the client's room well lit.
Check the client's temperature every 8 hr.
The Correct Answer is B
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Administering naloxone is not indicated for a seizure. Naloxone is used to reverse opioid overdose, not treat seizures.
Choice B reason:
Checking inside the child's mouth for bleeding is important after a seizure to ensure there is no injury to the oral cavity.
Choice C reason:
Giving the child a drink of water immediately after a seizure is not a priority intervention. The child may not be able to swallow properly immediately after a seizure.
Choice D reason:
Placing the child's head in a hyperextended position is not a recommended intervention after a seizure. It is important to maintain the child in a safe position and provide appropriate care after the seizure has ended.
Correct Answer is B
Explanation
Choice A reason:
Using a bulb syringe for suctioning is not the appropriate intervention for a choking infant. This may not effectively clear the airway obstruction.
Choice B reason:
Delivering back blows with the infant face down over the rescuer's arm is the recommended action for relieving a choking episode in an infant. This helps to dislodge the obstruction from the airway.
Choice C reason:
Placing the infant in a side-lying position and performing abdominal thrusts is the intervention for a conscious infant who is choking. This is not the appropriate action for an infant showing circumoral cyanosis.
Choice D reason:
Performing a head tilt and chin lift followed by giving rescue breaths is the procedure for providing rescue breaths in infant CPR. It is not the initial intervention for a choking infant.
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