Nokea
The client is at risk for septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk?
- A. Monitoring vital signs and oxygen saturation levels hourly
- B. Planning to give meningococcal polysaccharide vaccine
- C. Assessing neurological function with the Glasgow Coma Scale q2h
- D. Completing a thorough vascular assessment of all extremities q2h
Correct Answer: D
Rationale: Monitoring VS is indicated but does not address the complication of septic emboli. Immunization with the meningococcal polysaccharide vaccine (Menomune) is a preventive measure against meningitis and would not be included in treatment. Frequent neurological assessments are indicated but do not address the complication of septic emboli. Frequent vascular assessments will detect vascular compromise secondary to septic emboli. Early detection allows for interventions that will prevent gangrene and possible loss of limb.
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When implementing this medical order, which nursing action is most appropriate?
- A. Place the cooling blanket on top of the client.
- B. Wrap the cooling blanket in a light cloth cover.
- C. Add normal saline solution to the fluid chamber.
- D. Replace crushed ice periodically as it melts.
Correct Answer: B
Rationale: Wrapping the cooling blanket in a light cloth cover prevents direct skin contact, reducing the risk of thermal injury while allowing effective cooling.
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which action should the nurse implement?
- A. Notify the health-care provider as soon as possible (ASAP).
- B. Calm the client down by talking therapeutically.
- C. Increase the IV rate by 50 mL/hour.
- D. Lower the head of the bed immediately.
Correct Answer: D
Rationale: Light-headedness and low BP (84/40) in T1 SCI suggest orthostatic hypotension or neurogenic shock. Lowering the HOB (D) restores cerebral perfusion. Notifying the provider (A) or increasing IV rate (C) follows, and talking therapeutically (B) does not address the urgent issue.
The nurse is teaching the client who is scheduled for an outpatient EEG. Which instruction should the nurse include?
- A. Remove all hairpins before coming in for the EEG test.
- B. Avoid eating or drinking at least 6 hours prior to the test.
- C. Some hair will be removed with a razor to place electrodes.
- D. Have blood drawn for a glucose level 2 hours before the test.
Correct Answer: A
Rationale: In an EEG, electrodes are placed on the scalp over multiple areas of the brain to detect and record patterns of electrical activity. Preparation includes clean hair without any objects in the hair to prevent inaccurate test results. The client should not be NPO since a usual glucose level is important for normal brain functioning. The scalp will not be shaved; the electrodes are applied with paste. There is no indication to have a serum glucose drawn before the test.
The client is undergoing post-thrombolytic therapy for a stroke. The health-care provider has ordered heparin to be infused at 1,000 units per hour. The solution comes as 25,000 units of heparin in 500 mL of D5W. At what rate will the nurse set the pump?
Correct Answer: 20 mL/hr
Rationale: Calculate: (1,000 units/hr ÷ 25,000 units) × 500 mL = 20 mL/hr. The pump should be set to 20 mL/hr.
Which method is most appropriate to provide adequate nutrition for the client at this time?
- A. Crystalloid I.V. fluid
- B. Nasogastric tube feedings
- C. Total parenteral nutrition
- D. Gastrostomy tube feedings
Correct Answer: B
Rationale: Nasogastric tube feedings are appropriate for providing nutrition in clients with Guillain-Barré syndrome who have difficulty swallowing, as they are less invasive than total parenteral nutrition or gastrostomy tubes.