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 : Anticoagulants are medications that prevent blood clots. They are not typically used to manage fluid volume excess in left-sided heart failure. Instead, they may be used if the patient has an increased risk of clotting due to reduced mobility or atrial fibrillation, which can be associated with heart failure⁵.

Choice B reason : Antiembolism stockings are used to prevent deep vein thrombosis (DVT) and are not directly related to the management of fluid volume excess. They may be used in heart failure patients to prevent DVT due to reduced mobility but do not aid in fluid reduction⁵.

Choice C reason : Oxygen therapy can be used in left-sided heart failure to alleviate symptoms of dyspnea due to pulmonary congestion. However, it does not directly reduce fluid volume excess. It is a supportive treatment to ensure adequate oxygenation⁵.

Choice D reason : Diuretics are the primary treatment for reducing fluid volume excess in left-sided heart failure. They work by increasing urine output, which helps to reduce the volume of fluid in the body and alleviate symptoms such as pulmonary edema and peripheral edema⁵.

A. "I will call the doctor and get a prescription." B. "I will cover the catheter so he cannot see it." C. "I will provide more stimulation in his environment." D. "Let's wait until tonight to see if he continues this behavior."

Correct Answer is B

Explanation

Choice A reason :While consulting with the healthcare provider is important, immediate action is necessary to prevent harm. Waiting for a prescription may delay intervention.

Choice B reason : When a patient frequently attempts to remove their intravenous (IV) catheter, it's essential to address the behavior promptly to prevent potential complications such as catheter dislodgement, infection, or injury. The most appropriate initial response is to cover the catheter to reduce the patient's awareness and access, thereby decreasing the likelihood of tampering.

Choice C reason : Providing more stimulation could be counterproductive if the client is already agitated or confused. The nurse should assess the client's needs and environment to determine the appropriate level of stimulation.

Choice D reason : Waiting without taking action is not advisable as the client may harm themselves by removing the IV catheter. Immediate intervention is required to ensure the client's safety.

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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 caring for a client with left-sided heart failure. To reduce fluid volume excess, which of the following should the nurse anticipate using?

Correct Answer is D

Explanation

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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