The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

Perform active range of motion three times daily.

Maintain the head of bed in a flat or 30 degree position.

Teach measures to avoid the Valsalva maneuver.

Monitor for Battle's sign every four hours.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Performing active range of motion exercises may not be safe or appropriate immediately following a hemorrhagic stroke.

Choice B rationale: Maintaining the head of bed flat or at a 30-degree position might be used for ischemic strokes but not necessarily for hemorrhagic strokes.

Choice C rationale: Teaching measures to avoid the Valsalva maneuver (straining during activities like defecation) helps prevent sudden increases in intracranial pressure, which can be detrimental after a hemorrhagic stroke.

Choice D rationale: Monitoring for Battle's sign (bruising behind the ears associated with basilar skull fracture) is not relevant in the care of a hemorrhagic stroke.

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Correct Answer is B

Explanation

Choice A rationale: A calcium level of 8.6 mg/dL is within the normal range.

Choice B rationale: An elevated white blood cell count (WBC) of 19,000 mm3 indicates a potential infection or inflammatory process, requiring immediate attention, especially in a client receiving peritoneal dialysis.

Choice C rationale: A serum pH of 7.33 is within the normal range.

Choice D rationale: A hemoglobin level of 9 mg/dL might indicate anemia, but in a client receiving dialysis, it might not require immediate reporting unless it significantly drops further.

A. 1 B. 1.4 C. 1.5 D. 0.7

Correct Answer is B

Explanation

Choice A rationale: this corresponds with 25 mg which is lower than the prescribed amount.

Choice B rationale: To answer this question, we need to use the formula: volume (mL) = dose (mg) / concentration (mg/mL). We plug in the given values: volume (mL) = 35 mg / 25 mg/mL. We simplify the fraction: volume (mL) = 7/5. We convert the fraction to a

decimal: volume (mL) = 1.4. Therefore, the nurse should administer 1.4 mL of promethazine.

Choice C rationale: this corresponds with 37.5 mg which is too high.

Choice D rationale: this corresponds with 17.5 mg which is too low.

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The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PHCP)?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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