The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?
Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C).
Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg.
Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.
Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg.
The Correct Answer is A
A) Correct- Viral meningitis is an inflammation of the meninges (the protective membranes surrounding the brain and spinal cord) caused by a viral infection. While it can be serious, it is generally less severe than bacterial meningitis. Monitoring the client's temperature is an important aspect of care, as changes in temperature can indicate the progression of the illness or the effectiveness of interventions. A temperature increase from 101°F to 102°F is a subtle change but may still require close monitoring and symptom management. The practical nurse (PN) is capable of monitoring vital signs, including temperature, and reporting any changes to the registered nurse (RN) or healthcare provider. It is within the PN's scope of practice to assess and report changes in vital signs and general condition. The other scenarios involve more complex clinical situations that may require the expertise of registered nurses.
B) Incorrect- Myxedema coma is a severe form of hypothyroidism and is considered a medical emergency. Managing and assessing a client with myxedema coma requires advanced assessment, critical thinking, and interventions that are typically within the scope of registered nurses.
C) Incorrect- Diabetic ketoacidosis (DKA) is a complex condition that requires frequent monitoring of blood glucose levels, electrolytes, vital signs, and assessment of the level of consciousness. The change in the Glasgow Coma Scale score indicates a neurological deterioration that requires immediate attention and intervention, making it suitable for a registered nurse.
D) Incorrect- A subdural hematoma is a serious neurological condition that requires close monitoring of vital signs and neurological status. The change in blood pressure indicates a potential change in intracranial pressure and should be managed by registered nurses with expertise in neurological care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A) Correct- Assessing the child's pulse helps determine their cardiac status and whether they have a detectable heartbeat. This information is essential for deciding the appropriate interventions.
B) Correct- Placing a cervical collar is necessary if there is any suspicion of cervical spine injury due to the fall or submersion. This action helps stabilize the neck and prevent further damage to the spine.
C) Correct- Checking for open wounds is important to assess for potential sources of bleeding or infection that may require immediate attention.
D) Incorrect- While child safety is important, the immediate priority in this situation is assessing and stabilizing the child's medical condition. Child protective services may be involved later if there are concerns about the circumstances surrounding the incident.
E) Correct- Assessing the airway is of utmost importance to ensure that the child can breathe. In cases of near-drowning, ensuring a clear airway is crucial for oxygenation.
F) Incorrect- While establishing intravenous access may be important for certain interventions, it is not one of the immediate priorities in this situation. Ensuring the child's airway, breathing, and circulation take precedence.
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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