Nokea
A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage?
- A. Lying flat without a pillow with his head turned to the right.
- B. Lying flat with his head elevated on three pillows.
- C. Head of the bed elevated to 30 degrees with his head in a neutral position.
- D. Side-lying on his left side.
Correct Answer: C
Rationale: The head of the bed should be elevated 30 degrees to promote venous drainage and decrease intracranial pressure. The client's head should be in a midline, or neutral, position. Clients with supratentorial surgery should be positioned on the nonoperative side to prevent displacement of the cranial contents by gravity.
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The nurse instructs the client in mixing and administering regular and NPH insulin. Which of the following statements indicates that the client needs additional instruction?
- A. I draw up the regular insulin first
- B. I shake the bottle of NPH insulin before drawing it up
- C. I store the insulin in a cool place
- D. I insert the needle at a 90-degree angle
Correct Answer: B
Rationale: Shaking NPH insulin can damage it; it should be gently rolled. Drawing up regular insulin first, cool storage, and a 90-degree injection angle are correct practices.
After teaching a mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates:
- A. Possible partial paralysis.
- B. Possible lower limb defect.
- C. Immature central nervous system.
- D. Possible injury to nerves that innervate the legs.
Correct Answer: C
Rationale: A positive Babinski's reflex in neonates indicates an immature central nervous system, a normal finding that typically disappears by 1–2 years.
Which of the following would demonstrate the correct technique for applying an elastic bandage to a leg?
- A. Increase tension with each successive turn of the bandage.
- B. Start at the distal end of the extremity and move toward the trunk.
- C. Secure the bandage with clips over the area of the inner thigh.
- D. Overlap each layer twice when wrapping.
Correct Answer: B
Rationale: Starting at the distal end and moving toward the trunk promotes venous return and prevents constriction.
A client with a history of depression is prescribed bupropion (Wellbutrin). The nurse should instruct the client to:
- A. Avoid alcohol consumption.
- B. Take the medication at bedtime.
- C. Take the medication with meals.
- D. Stop the medication if mood improves.
Correct Answer: A
Rationale: Alcohol should be avoided with bupropion to prevent seizures.
The nurse is assessing a client with suspected meningitis. Which finding requires immediate action?
- A. Nuchal rigidity
- B. Headache
- C. Photophobia
- D. Fever of 100.4°F (38°C)
Correct Answer: A
Rationale: Nuchal rigidity is a critical sign of meningitis, indicating meningeal irritation and requiring immediate medical intervention to prevent complications.