Nokea
A 15-year old is admitted following a motor vehicle accident. Examination reveals that the client has a closed head injury, a linear fracture of the temporal bone, a fracture of the mandible, and multiple abrasions. Upon admission, he is very drowsy. Which of the following orders would not be a part of the patient's care?
- A. Elevate the head 30°
- B. Apply Neosporin (neomycin) ointment to abrasions
- C. Polycillin (ampicillin) 500 mg IVPB q 6 hr
- D. Demerol (meperidine) 75 mg q 3-4 hr PRN pain
Correct Answer: D
Rationale: Demerol is contraindicated in head injuries due to its potential to mask neurological changes and increase intracranial pressure.
You may also like to solve these questions
The nurse is caring for a client with a history of schizophrenia.
- A. Which client behavior indicates a positive response to antipsychotic medication?
- B. Increased social withdrawal.
- C. Improved ability to focus on tasks.
- D. Frequent auditory hallucinations.
- E. Increased agitation and pacing.
Correct Answer: B
Rationale: Improved ability to focus on tasks indicates reduced psychotic symptoms and better cognitive function, a positive response to antipsychotics. Withdrawal, hallucinations, and agitation suggest poor response.
Docusate sodium (Colace) is ordered for an adult who had a myocardial infarction yesterday. The client asks the nurse why docusate sodium is prescribed. The nurse's response should include which information?
- A. Colace is prescribed to make it take longer for blood to clot.
- B. Colace makes it easier for the client to relax and reduce stress.
- C. Colace helps lower cholesterol levels.
- D. Colace reduces straining at stool.
Correct Answer: D
Rationale: Docusate sodium is a stool softener, reducing straining during bowel movements, which decreases cardiac strain post-MI.
Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?
- A. Touring the coronary intensive unit
- B. Mailing a video tape to the home
- C. Assessing the client's learning style
- D. Administering a written pre-test
Correct Answer: C
Rationale: Assessing the client's learning style. Tailoring teaching to the client's learning preferences enhances understanding.
After the anesthesiologist administers an epidural to a woman in labor, which of the following nursing actions has the HIGHEST priority?
- A. Decrease IV fluids.
- B. Assess the fetal heart monitor.
- C. Place the mother on her right side.
- D. Obtain the blood pressure.
Correct Answer: D
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring the priority to detect complications. Options A, B, and C are secondary or incorrect.
The nurse is caring for a client who is postoperative day 1 after a total shoulder replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of a sling
- B. Administer pain medication as needed
- C. Keep the affected arm in adduction
- D. Monitor the surgical dressing for drainage
Correct Answer: A
Rationale: Using a sling maintains shoulder immobilization, preventing dislocation post-replacement. Options B, C, and D are secondary: pain management is routine, adduction is incorrect, and dressing monitoring is less urgent.