When caring for an unconscious client with increasing intracranial pressure, the nursing intervention that is contraindicated is :
Elevating the head of the bed 20 degrees
Cleansing the eyes every 4 hours with normal saline
Lubricating the skin with baby oil
Suctioning the oropharynx routinely
The Correct Answer is D
Choice A reason : Elevating the head of the bed to 20 degrees can help reduce intracranial pressure by promoting venous drainage from the brain. It is a recommended practice unless contraindicated by other conditions³.
Choice B reason : Cleansing the eyes with normal saline every 4 hours is a standard care procedure to maintain eye hygiene and prevent infection, especially when the blink reflex may be compromised in an unconscious patient³.
Choice C reason : Lubricating the skin with baby oil is a common practice to prevent dryness and maintain skin integrity. It is not contraindicated unless the patient has specific allergies or skin conditions that require different care³.
Choice D reason : Suctioning the oropharynx routinely is contraindicated as it can stimulate the vagus nerve and potentially increase intracranial pressure. Suctioning should be performed cautiously and only when necessary³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason : Spironolactone is a potassium-sparing diuretic, which means it helps the body get rid of excess water without causing potassium loss. Therefore, a decreased potassium level would not be expected.
Choice B reason : Spironolactone can lead to hyperkalemia (increased potassium levels) and hyponatremia (decreased sodium levels) because it causes the kidneys to excrete sodium while retaining potassium.
Choice C reason : A decreased phosphate level is not a typical finding associated with spironolactone use. Phosphate levels are more commonly affected by renal function and parathyroid hormone levels.
Choice D reason : A decreased chloride level is not specifically associated with spironolactone. While electrolyte imbalances can occur, spironolactone primarily affects potassium and sodium balance.
Correct Answer is D
Explanation
Choice A reason : Nitroglycerin is used to treat angina pectoris and does not typically cause a decrease in potassium levels¹.
Choice B reason : Metoprolol is a beta-blocker used to treat high blood pressure and heart failure but is not known to significantly affect potassium levels¹.
Choice C reason : Spironolactone is a potassium-sparing diuretic and would not contribute to low potassium levels; it is more likely to cause hyperkalemia¹.
Choice D reason : Furosemide is a loop diuretic that can lead to hypokalemia by increasing the excretion of potassium in the urine. It is known to contribute to low potassium levels and should be identified as the medication affecting this lab value¹².
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