Nokea
A client begins to experience seizure activity while in bed. The nurse should provide which intervention to prevent aspiration?
- A. Raise the head of the bed.
- B. Loosen restrictive clothing.
- C. Remove the pillow and raise the padded side rails.
- D. Position the client on the side with the head flexed forward.
Correct Answer: D
Rationale: Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates the drainage of secretions, which could help prevent aspiration. The nurse would not raise the head of the client's bed. The nurse would remove restrictive clothing and the pillow and raise the padded side rails, if present, but these actions would not decrease the risk of aspiration; rather, they are general safety measures to use during seizure activity.
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A client tells the clinic nurse that her skin is very dry and irritated. Which product should the nurse suggest that the client apply to the dry skin?
- A. Myoflex
- B. Aspercreme
- C. Topical emollient
- D. Acetic acid solution
Correct Answer: C
Rationale: A topical emollient is used for dry, cracked, and irritated skin. Aspercreme and Myoflex are used to treat muscular aches. Acetic acid solution is used for irrigating, cleansing, and packing wounds infected with Pseudomonas aeruginosa.
The nurse caring for a child who has sustained a head injury notes that the primary health care provider has documented decorticate posturing. During the assessment of the child, the nurse notes the extension of the upper extremities and the internal rotation of the upper arms and wrists. The nurse also notes that the lower extremities are extended, with some internal rotation noted at the knees and feet. On the basis of these findings, what is the initial nursing action?
- A. Document that the original positioning is unchanged.
- B. Attempt to assess the flexibility of the child's lower extremities.
- C. Plan to continue to monitor the child for posturing every 2 hours.
- D. Notify the primary health care provider of the change in posturing.
Correct Answer: D
Rationale: Decorticate (flexion) posturing refers to the flexion of the upper extremities and the extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate (extension) posturing involves the extension of the upper extremities with the internal rotation of the upper arms and wrists. The lower extremities will extend with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Although documentation is appropriate, it is not the initial action in this situation. The other options are not appropriate.
The nurse prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the unlicensed assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction?
- A. A foot board
- B. Extra pillows
- C. A bed trapeze
- D. An electric bed
Correct Answer: C
Rationale: A trapeze is essential to allow the client to lift straight up while being moved so that the amount of pull exerted on the limb in traction is not altered. A foot board and extra pillows do not facilitate moving. Either an electric bed or a manual bed can be used for traction, but this does not specifically assist the client with moving in bed.
The nurse is reviewing the primary health care provider's prescriptions for a child who was admitted to the hospital with vaso-occlusive pain crisis resulting from sickle cell anemia. Which primary health care provider prescription should the nurse question?
- A. Bed rest
- B. Intravenous fluids
- C. Supplemental oxygen
- D. Meperidine hydrochloride
Correct Answer: D
Rationale: Meperidine hydrochloride is contraindicated for ongoing pain management because of the increased risk of seizures associated with the use of the medication. The management of vaso-occlusive pain generally includes the use of strong opioid analgesics such as morphine sulfate or hydromorphone. These medications are usually most effective when given as a continuous infusion or at regular intervals around the clock. The remaining options are appropriate prescriptions for treating vaso-occlusive pain crisis.
The nurse is caring for a client who is scheduled an arthrogram involving the use of a contrast medium. Which action by the nurse is the priority?
- A. Determining the presence of client allergies
- B. Asking if the client has any last-minute questions
- C. Telling the client to try to void before leaving the unit
- D. Emphasizing to the client the importance of remaining still during the procedure
Correct Answer: A
Rationale: Because of the risk of allergy to contrast medium, the nurse places the highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and reminds the client about the need to remain still during the procedure. It is helpful to have the client void before the procedure for comfort.