A nurse is reviewing a patient’s medical record.
After reviewing the medical data, which of the following actions should the nurse plan to take?
Initiate seizure precautions.
Assist the patient to the bathroom.
Keep the patient’s head in a mid position.
Decrease oxygen to 1.5 L/min via nasal cannula.
The Correct Answer is A
Choice A rationale
Without specific patient data, it’s challenging to provide a detailed rationale.
However, initiating seizure precautions could be necessary if the patient’s medical record indicates a history of seizures or a condition that increases the risk of seizures.
Choice B rationale
Assisting the patient to the bathroom is a routine nursing intervention and would not typically be determined based on a review of the patient’s medical record.
Choice C rationale
Keeping the patient’s head in a mid position would depend on the patient’s condition and would not typically be determined based on a review of the patient’s medical record.
Choice D rationale
Decreasing oxygen to 1.5 L/min via nasal cannula would depend on the patient’s oxygen saturation levels and overall respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Applying mystatin cream to the blistered areas is not typically recommended for herpes zoster lesions. Mystatin is an antifungal medication, and herpes zoster is caused by a virus, not a fungus.
Choice B rationale
Implementing contact precautions is recommended for patients with widespread herpes zoster lesions. This helps to prevent the spread of the virus to other people.
Choice C rationale
Using warm compresses on the crusted lesions is not typically recommended. While warm compresses can help with some skin conditions, they are not usually part of the care plan for herpes zoster.
Choice D rationale
Administering the shingles vaccine is not typically done once a patient already has widespread herpes zoster lesions. The vaccine is used to prevent shingles, not to treat active cases.
Correct Answer is A
Explanation
Choice A rationale
Limiting sodium intake to no more than 2,000 milligrams per day is a recommended strategy to prevent hypertension. Excessive sodium intake can increase blood pressure by causing the body to retain fluid, which increases the volume of blood and subsequently, blood pressure.
Choice B rationale
While regular exercise is beneficial for overall health, the statement “I should exercise for 30 minutes three times per week” may not be sufficient for hypertension prevention. The American Heart Association recommends at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity, or a combination of both, preferably spread throughout the week.
Choice C rationale
Eating fish once per week is not a specific recommendation for preventing hypertension. While fish can be a good source of lean protein and omega-3 fatty acids, it does not directly relate to blood pressure control.
Choice D rationale
The statement “With a BMI of 30, I should maintain my current weight” is incorrect. A BMI of 30 falls into the category of obesity, which is a risk factor for hypertension. Weight loss is recommended for hypertension prevention and control in overweight and obese individuals.
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