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Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.

Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Assess the client's pain

Increase the propofol infusion

Notify the social worker the client is awake.

Have the client sign consent forms for procedures already performed

Consider extubating the client

Determine the client's decision-making ability

Decrease the noise and light stimuli in the room as much as possible

Explain all procedures

Answer and Explanation

Correct Answer : A,F,G,H

A. Assess the client's pain: The client has experienced significant trauma, undergone surgery, and may be in pain or discomfort as she regains consciousness. Pain assessment is crucial for adequate pain management and to prevent agitation or hemodynamic instability.
B. Increase the propofol infusion: Increasing sedation should not be the first response. Instead, assess the client’s pain and agitation, and if necessary, adjust sedation based on clinical need and provider recommendations.
C. Notify the social worker the client is awake: A social worker may be involved in care planning, but waking up does not require immediate notification.
D. Have the client sign consent forms for procedures already performed: If the client was incapacitated at the time of previous procedures, consent was likely obtained from a legal surrogate. Retroactive consent is not legally valid.
E. Consider extubating the client: The decision to extubate should be based on respiratory assessments, arterial blood gas (ABG) results, and overall stability, not just the client waking up.
F. Determine the client’s decision-making ability: As the client becomes more aware, it is important to assess cognitive function and orientation to determine if she can participate in decisions regarding her care. If the client is alert and coherent, she may be able to provide informed consent for further treatments.
G. Decrease the noise and light stimuli in the room as much as possible: Critically ill patients can become disoriented and agitated as they wake up. A calm environment helps reduce stress and delirium, improving recovery and promoting rest.
H. Explain all procedures: The client is waking up in an unfamiliar environment (intubated in the ICU), which can be frightening and disorienting. Explaining procedures provides reassurance and can help reduce anxiety and agitation.

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Correct Answer is B

Explanation

A. Sodium intake with meals and snacks affects the blood pressure. While sodium can contribute to blood pressure increases, the primary reason for monitoring blood pressure in this case is to detect the kidney-related hypertension.

B. Elevated blood pressure must be anticipated and identified quickly. Blood pressure can increase significantly in acute glomerulonephritis due to fluid retention and kidney impairment. Frequent monitoring helps to identify and treat elevated blood pressure early, preventing complications.

C. Blood pressure fluctuations mean that the condition has become chronic. Acute glomerulonephritis typically causes fluctuating blood pressure, but this does not necessarily indicate chronic disease.

D. Hypotension leading to sudden shock can develop at any time. Hypotension is less common in acute glomerulonephritis compared to hypertension, making this response less accurate.

A. Measure body temperature. B. Check for pedal edema. C. Observe color of urine. D. Assess skin turgor.

Correct Answer is C

Explanation

A. While measuring body temperature is important for infection monitoring, it is not the primary concern after prasugrel administration.
B. Pedal edema is not a common side effect of prasugrel and does not directly relate to its adverse effects.
C. Prasugrel is an antiplatelet medication that increases the risk of bleeding. Monitoring for signs of bleeding, such as blood in the urine (hematuria), is important to assess for adverse effects.
D. Assessing skin turgor is important for hydration status but does not address bleeding risks associated with prasugrel.

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Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Correct Answer is B

Explanation

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care?

Correct Answer is C

Explanation

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

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Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.

Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.