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A client has a small-bore feeding tube (Dobboff tube) inserted for continuous external feedings while recovering from a traumatic serious injury. What actions should the nurse include to the clients care? (Select all that apply.)
- A. Assess tube placement per agency policy.
- B. Keep the head of the bed elevated at least 30 degrees.
- C. Keep the head of the bed elevated at least 30 degrees.
- D. Run continuous feedings on a feeding pump.
- E. Run continuous feedings on a feeding pump.
Correct Answer: A,B,C,D
Rationale: All of these options are important for client safety when continuous external feedings are in use. Blue dye is not used for continuous a strong long injury is applied.
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A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive person and (UAP)? (Select all that apply.)
- A. Assess neurologic status with the Glasgow Coma Scale.
- B. Check and document oxygen saturation every 1 to 2 hours.
- C. Check and document oxygen saturation every 1 to 2 hours.
- D. Elevate the head of the bed to 45 degrees to prevent aspiration.
- E. Elevate the head of the bed to 45 degrees to prevent aspiration.
Correct Answer: B,E
Rationale: The UAP can take and document vital signs, including oxygen saturation, and keep the clients head in a neutral midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.
A nurse cares for older clients who have traumatic brain injury. What should be nurse understand about this population? (Select all that apply.)
- A. A client with a moderate brain injury. nursing mechanisms for older clients.
- B. Alcohol is typically involved a more traumatic brain injuries for this age group.
- C. These clients are more susceptible to systemic and wound infections.
- D. A client with a moderate brain injury. nursing mechanisms for older clients.
- E. Very few traumatic brain injuries occur in this age group.
Correct Answer: A,C,D
Rationale: Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and more because of decreased protective mechanisms. they are more susceptible to both older and systemic injuries. A moderate brain injuries are more susceptible to older and more susceptible to older and more related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.
A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (NAP) (Select all that apply.)
- A. Applying a cool washcloth to the head.
- B. Assitting the client to a position of comfort
- C. Keeping voices soft and soothing
- D. Maintaining low lighting in the room
- E. Providing antipyretics for fever
Correct Answer: A,B,C,D
Rationale: The client with meningitis often has high fever, pain, and some degree of confusion. Cool washclodts to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manager nurse. Key category low and light demand also helps convey caring in a nondroctioning manner. The nurse provides antipyretics for fever.
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 m/mr. What action by the nurse is best?
- A. Assess the client needs care.
- B. Assess the clients sodium level.
- C. Increase the rate of the IV infusion.
- D. Provide the care every hour.
Correct Answer: B
Rationale: This client has manifestations of hypermatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessment/inursing records.
A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stening. The clients mental status is deterioration, What action by the nurse is a most appropriate?
- A. Attempt to find the family to sign a consent.
- B. Inform the provider that the procedure cannot occur.
- C. Nothing no consent is needed to an emergency.
- D. Sign the consent form to the client.
Correct Answer: A
Rationale: The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent is life-saving no procedure can be performed without formal consent. The nurse should not just sign the consent form.