An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)
Place a bedside commode next to bed.
Measure neurological vital signs every 4 hours.
Suction oral cavity every 4 hours.
Encourage family to participate in the client's care.
Play classical music in room while client is
Correct Answer : A,B,D
The correct answer is a. Place a bedside commode next to bed., b. Measure neurological vital signs every 4 hours., d. Encourage family to participate in the client’s care.
Choice A rationale:
Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.
Choice B rationale:
Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.
Choice C rationale:
Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management. Routine suctioning can also cause discomfort and potential injury.
Choice D rationale:
Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process. Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.
Choice E rationale:
Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation. The effectiveness of music therapy can vary based on individual preferences.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D,E
Explanation
A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to
the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.
Correct Answer is ["9"]
Explanation
Here are the steps you can follow to calculate the infusion pump flow rate:
Step 1: Calculate the prescribed dose in mcg/min
- Dose per weight: 2 mcg/kg/min * 60 kg = 120 mcg/min
Step 2: Convert the concentration in the IV bag to mcg/mL
- Convert mg to mcg: 200 mg * 1000 mcg/mg = 200,000 mcg
- Concentration: 200,000 mcg / 250 mL = 800 mcg/mL
Step 3: Calculate the flow rate in mL/min
- Flow rate: 120 mcg/min / 800 mcg/mL = 0.15 mL/min
Step 4: Convert the flow rate to mL/hour
- Hour conversion: 0.15 mL/min * 60 min/hour = 9 mL/hour
Therefore, the nurse should program the infusion pump to deliver 9 mL/hour.
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