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 A

Explanation

Choice A reason : Standard precautions are the primary strategy for the prevention and control of hepatitis C virus (HCV) transmission. According to the Centers for Disease Control and Prevention (CDC), standard precautions include hand hygiene and the use of personal protective equipment to prevent contact with blood and other potentially infectious materials¹. Since HCV is primarily transmitted through blood-to-blood contact, standard precautions are sufficient for routine care of patients with hepatitis C².

Choice B reason : Airborne precautions are not necessary for hepatitis C as it is not spread through the air. These precautions are used for diseases that are transmitted through airborne droplet nuclei or dust particles containing the infectious agent, such as tuberculosis, measles, or chickenpox¹.

Choice C reason : Droplet precautions are also not required for hepatitis C because it is not spread through droplets in the air. Droplet precautions are used for infections that can be transmitted through large droplets expelled during coughing, sneezing, talking, or during procedures such as suctioning and bronchoscopy¹.

Choice D reason : Contact precautions are not specifically required for hepatitis C unless there is a risk of blood contamination. Contact precautions are typically used for infections that are spread by direct or indirect contact with the patient or the patient's environment, such as gastrointestinal, respiratory, skin, or wound infections¹.

A. Nitroglycerin B. Metoprolol C. Spironolactone D. Furosemide

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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