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A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first?

A client who is post-coronary artery bypass graft (CABG), has total cholesterol of 318 mg/dL, and is prescribed atorvastatin

A client who has pneumonia, a WBC count of 11,500/mm³, and is prescribed piperacillin

A client who has renal failure, a serum potassium of 5.8 mEq/L, and is prescribed sodium polystyrene sulfonate

A client who has anemia, hemoglobin of 11 g/dL, and is prescribed epoetin alfa

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect because a client who is post-CABG and has high cholesterol is not in immediate danger, as atorvastatin is a long-term medication that lowers cholesterol and prevents cardiovascular complications.

Choice B Reason: This is incorrect because a client who has pneumonia and a slightly elevated WBC count is not in immediate danger, as piperacillin is an antibiotic that treats bacterial infections.

Choice C Reason: This is correct because a client who has renal failure and a high serum potassium level is in immediate danger, as sodium polystyrene sulfonate is an emergency medication that lowers potassium and prevents cardiac arrhythmias.

Choice D Reason: This is incorrect because a client who has anemia and a mild hemoglobin deficiency is not in immediate danger, as epoetin alfa is a long-term medication that stimulates red blood cell production and improves oxygen delivery.

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Correct Answer is D

Explanation

Choice A Reason: This choice is incorrect because providing a brightly lit environment may stimulate the client and increase the intracranial pressure. A brightly lit environment is an environment that has a high level of illumination or brightness. It may be used for clients who have depression, seasonal aﬀective disorder, or insomnia, but it does not help to reduce the intracranial pressure.

Choice B Reason: This choice is incorrect because teaching controlled coughing and deep breathing may increase the intrathoracic pressure and increase the intracranial pressure. Controlled coughing and deep breathing are techniques that help to clear the airway and improve lung expansion. They may be used for clients who have respiratory infections, chronic obstructive pulmonary disease, or postoperative complications, but they do not help to reduce the intracranial pressure.

Choice C Reason: This choice is incorrect because encouraging a minimum intake of 2000 mL (67.5 oz) of clear ﬂuids per day may cause ﬂuid overload and increase the intracranial pressure. Fluid overload is a condition in which the body has too much ﬂuid, which can impair the function of the heart, lungs, and kidneys. Therefore, restricting ﬂuid intake and using diuretics may be indicated for clients who have increased intracranial pressure.

Choice D Reason: This choice is correct because elevating the head of the bed 20° may help to improve the venous drainage and decrease the intracranial pressure. As explained above, positioning the client in a semi-Fowler's or high-Fowler's position can facilitate breathing and prevent further complications. However, elevating the head of the bed more than 30° may decrease the cerebral perfusion pressure (CPP), which is the diﬀerence between the mean arterial pressure (MAP) and the intracranial pressure (ICP). A normal CPP range is 70 to 100 mm Hg, and a low CPP (<50 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, elevating the head of the bed to a moderate angle (20°) may be optimal for clients who have increased ICP.

A. Verify the prescribed ventilator settings daily. B. Apply restraints if the client becomes agitated. C. Administer pantoprazole as prescribed. D. Reposition the endotracheal tube to the opposite side of the mouth daily. E. Elevate the head of the bed to at least 30°.

Correct Answer is ["A","C","E"]

Explanation

Choice A Reason: This choice is correct because verifying the prescribed ventilator settings daily is an important intervention to ensure that the client is receiving adequate ventilation and oxygenation. The ventilator settings include parameters such as tidal volume, respiratory rate, fraction of inspired oxygen (FiO2), positive end-expiratory pressure (PEEP), and peak inspiratory pressure (PIP). The nurse should check that the settings match the prescription and report any changes or alarms to the provider.

Choice B Reason: This choice is incorrect because applying restraints if the client becomes agitated is not a recommended intervention to prevent complications. Restraints may cause injury, infection, or psychological distress to the client and increase the risk of ventilator-associated pneumonia (VAP). The nurse should use alternative methods to manage agitation, such as sedation, analgesia, or environmental modification.

Choice C Reason: This choice is correct because administering pantoprazole as prescribed is an important intervention to prevent complications. Pantoprazole is a proton pump inhibitor (PPI) that reduces the production of stomach acid and prevents gastroesophageal reﬂux disease (GERD) and stress ulcers. These conditions can cause aspiration, bleeding, or infection in clients who are receiving mechanical ventilation.

Choice D Reason: This choice is incorrect because repositioning the endotracheal tube to the opposite side of the mouth daily is not a recommended intervention to prevent complications. Repositioning the endotracheal tube may cause trauma, bleeding, or displacement of the tube, which can compromise the airway and ventilation of the client. The nurse should secure the tube with tape or a device and check its position regularly using chest x-ray or end-tidal CO2 monitoring.

Choice E Reason: This choice is correct because elevating the head of the bed to at least 30° is an important intervention to prevent complications. Elevatin the head of the bed helps to reduce the risk of aspiration, which is the inhalation of gastric contents or secretions into the lungs. Aspiration can cause pneumonia, atelectasis, or respiratory failure in clients who are receiving mechanical ventilation.

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A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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