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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason : Ecchymosis of the extremities is not a typical finding associated with common bile duct obstruction. It refers to bruising, which can have many causes unrelated to bile duct issues⁴.

Choice B reason : Straw-colored urine is usually a sign of well-hydrated and healthy individuals. In the case of common bile duct obstruction, the urine may actually become darker due to increased bilirubin levels⁴.

Choice C reason : Tenderness in the left upper abdomen is more commonly associated with issues related to the stomach, spleen, or pancreas, not the common bile duct⁴.

Choice D reason : Clay stools are a classic symptom of common bile duct obstruction. When bile flow is blocked, stools can lose their normal brown color and appear pale or clay-colored due to the absence of bilirubin⁴.

A. Give morphine IV. B. Start an IV infusion of lactated Ringer's. C. Initiate cardiac monitoring. D. Administer oxygen therapy.

Correct Answer is D

Explanation

Choice A reason : While morphine IV can be used to alleviate pain and anxiety, it is not the first-line intervention for a pulmonary embolism. The primary concern in pulmonary embolism is to address the impaired gas exchange and potential hypoxemia¹.

Choice B reason : Starting an IV infusion of lactated Ringer's may be part of the overall management but is not the immediate priority. The initial focus should be on stabilizing the client's respiratory status¹.

Choice C reason : Initiating cardiac monitoring is important for observing the client's heart function, as pulmonary embolism can lead to strain on the heart. However, the first intervention should be to ensure adequate oxygenation¹.

Choice D reason : Administering oxygen therapy is the most critical initial intervention for a client with a pulmonary embolism. Oxygen therapy helps to manage hypoxemia and reduce the workload on the heart by improving oxygen saturation levels¹.

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When caring for an unconscious client with increasing intracranial pressure, the nursing intervention that is contraindicated is :

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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