A nurse is reviewing the prescriptions for a client who has a new diagnosis of bacterial meningitis. Which of the following prescriptions should the nurse clarify with the provider?
Place the client on droplet precautions.
Perform a cranial nerve assessment on the client every 2 hr.
Assist the client out of bed three times per day.
Assess the client's weight daily.
The Correct Answer is B
Choice A rationale:
Placing the client on droplet precautions is appropriate for bacterial meningitis, as it is spread through respiratory droplets. This measure helps prevent the spread of infection to others.
Choice B rationale:
The nurse should clarify the prescription to perform a cranial nerve assessment every 2 hours. While cranial nerve assessment is crucial in monitoring neurological status, performing it every 2 hours is excessive and not supported by evidence-based practice. Frequent assessments can be uncomfortable for the client and may not provide additional meaningful information within such a short interval.
Choice C rationale:
Assisting the client out of bed three times per day is essential for promoting mobility and preventing complications such as pressure ulcers and muscle weakness. This prescription is appropriate and does not require clarification.
Choice D rationale:
Assessing the client's weight daily is essential in monitoring fluid balance and nutritional status. There is no need to clarify this prescription, as it is a standard practice in caring for clients with bacterial meningitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Rationale:
A) Place the client in a room with negative airflow: Disseminated herpes zoster (shingles) requires airborne precautions because the virus can become aerosolized. A room with negative airflow helps prevent the spread of the virus to other areas, protecting healthcare workers and other patients from infection.
B) Remove isolation gown after leaving the client's room: Isolation gowns should be removed before leaving the client's room to prevent the spread of contaminants to other areas. This intervention is important for infection control but is not specific to the requirement for negative airflow in cases of disseminated herpes zoster.
C) Apply ketoconazole to the lesions three times per day: Ketoconazole is an antifungal medication and is not used for treating herpes zoster, which is caused by a viral infection. Antiviral medications, such as acyclovir, are appropriate for treating herpes zoster lesions.
D) Provide the client with eye protection for ultraviolet B light therapy: Eye protection is necessary during UVB light therapy to protect the eyes, but UVB light therapy is not a standard treatment for disseminated herpes zoster. The priority intervention is to prevent the spread of the infection by using a negative airflow room.
Correct Answer is B
Explanation
Choice A rationale:
A PT (Prothrombin Time) of 12 seconds is not indicative of the effectiveness of heparin therapy for a pulmonary embolism. PT measures the extrinsic pathway of the coagulation cascade, and it is more relevant to monitor in patients on warfarin therapy.
Choice B rationale:
The aPTT (Activated Partial Thromboplastin Time) of 75 seconds is the correct choice as it reflects the effectiveness of unfractionated heparin therapy. Heparin works by inhibiting clotting factors in the intrinsic pathway, and the aPTT is used to monitor heparin's anticoagulant effect. The normal range for aPTT is typically 25-35 seconds.
Choice C rationale:
An INR (International Normalized Ratio) of 1.1 is not the appropriate parameter to assess the effectiveness of heparin therapy. INR is primarily used to monitor the effectiveness of oral anticoagulants like warfarin, not heparin.
Choice D rationale:
The platelet count of 200,000/mm² is not a suitable parameter to evaluate the effectiveness of heparin therapy. Platelet count is important for assessing the risk of bleeding or clotting disorders but does not directly measure the impact of heparin on clotting factors.
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