Nokea
A nurse is monitoring a client's intracranial pressure (ICP) after a motor vehicle accident. Upon checking the ICP, the nurse knows to contact the physician. What reading would warrant this action?
- A. 8 mm Hg
- B. 14 mm Hg
- C. 18 mm Hg
- D. 22 mm Hg
Correct Answer: D
Rationale: Normal ICP is 5-15 mm Hg. A reading of 22 mm Hg (D) indicates elevated ICP, requiring immediate physician notification. Lower readings (A, B, C) are within or near normal.
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The nurse is caring for a client who just arrived in the PACU following a colonoscopy with polyp removal. The client's level of sedation is assessed using the Ramsay Sedation Scale (RSS). The client responds quickly, but only to commands. What Ramsay score would the nurse chart for this client?
- A. RSS 1
- B. RSS 2
- C. RSS 3
- D. RSS 4
- E. RSS 5
- F. RSS 6
Correct Answer: C
Rationale: RSS 3 indicates a client who responds quickly to commands only, consistent with moderate sedation post-procedure.
The nurse is preparing to remove a peripheral IV from a client. Which nursing action is the priority with this procedure?
- A. checking for an intact catheter tip
- B. washing the hands and donning gloves
- C. charting the client's tolerance to the procedure
- D. removing catheter slowly using the dominant hand
- E. holding pressure on the site until hemostasis is achieved
Correct Answer: E
Rationale: Holding pressure until hemostasis (E) is the priority to prevent bleeding, especially in clients with anticoagulation or clotting issues.
The nurse is caring for a client who was admitted with an upper respiratory infection. The client's temperature is 102.4°F, and he is confused. In the last 2 hours, systolic blood pressure has dropped from 138 to 90. The nurse should perform which intervention? Select all that apply.
- A. obtain blood cultures
- B. place the client on NPO status
- C. administer supplemental oxygen
- D. administer antipyretics as ordered
- E. encourage rest and limit physical activity
- F. provide a warming blanket to alleviate chills
Correct Answer: A,C,D,E
Rationale: Fever, confusion, and hypotension suggest sepsis, requiring blood cultures (A), oxygen (C), antipyretics (D), and rest (E). NPO (B) is unnecessary, and warming blankets (F) may worsen fever.
The nurse is assessing a client with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which finding would be expected for this client?
- A. hypoxemia and hypocarbia
- B. hyperoxemia and hypocarbia
- C. hypoxemia and hypercarbia
- D. hyperoxemia and hypercarbia
Correct Answer: C
Rationale: COPD exacerbation causes airway obstruction, leading to hypoxemia (low oxygen) and hypercarbia (high CO2) due to impaired gas exchange.
A client is scheduled for a CT of the brain with and without IV contrast dye to evaluate a possible hemorrhage. Which finding in the client's history should the nurse report immediately to the health care provider?
- A. allergy to shellfish
- B. history of schizophrenia
- C. allergy to cephalosporins
- D. presence of a pacemaker
Correct Answer: A
Rationale: Shellfish allergy indicates a potential iodine allergy, which is critical for IV contrast safety, requiring immediate provider notification.