Nokea
A client who experienced a traumatic brain injury has a Glasgow Coma Scale score of 6 and is at risk for increased intracranial pressure (ICP). Which position should the nurse maintain for this client?
- A. Supine with head turned to the right
- B. Prone with the head straight
- C. Semi-Fowler's at 30 degrees
- D. High Fowler's at 90 degrees
Correct Answer: C
Rationale: For a GCS of 6 with ICP risk, semi-Fowler's at 30 degrees (C) optimizes venous drainage, reducing ICP. Supine (A) or prone (B) increases pressure. High Fowler's (D) may destabilize. C is correct. Rationale: 30-degree elevation balances ICP reduction and perfusion, per neurocare standards, critical in severe brain injury.
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The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?
- A. Call a code.
- B. Administer a bronchodilator.
- C. Contact the health care provider.
- D. Disconnect the suction source from the catheter.
Correct Answer: D
Rationale: A stuck catheter with coughing and wheezing suggests obstruction or bronchospasm; disconnecting the suction source (D) is the priority to relieve pressure and attempt removal. Calling a code (A) or provider (C) delays action. Bronchodilators (B) treat wheezing but not the immediate issue. D is correct. Rationale: Disconnecting stops suction trauma, allowing catheter withdrawal and airway reassessment, a critical first step per emergency airway protocols.
After a day, Mr Gary's wife shouted at the nurse and said 'You're not doing your job right! My husband is dying because of you!' This is an example of?
- A. Denial
- B. Anger
- C. Bargaining
- D. Depression
Correct Answer: B
Rationale: Shouting 'You're not doing your job is anger (B), per Kubler-Ross lashing out in grief. Denial (A) rejects, bargaining (C) pleads, depression (D) withdraws. Anger targets others, fitting her outburst, making it correct.
Which of the following is TRUE about the blood pressure determinants?
- A. Hypervolemia lowers BP
- B. Hypervolemia increases GFR
- C. HCT of 70% might decrease or increase BP
- D. Epinephrine decreases BP
Correct Answer: C
Rationale: Hematocrit (HCT) 70% e.g., polycythemia can raise BP (viscosity) or lower it (poor flow), unlike hypervolemia (raises BP, GFR), or epinephrine (raises BP). Nurses assess this e.g., in anemia for variable impacts, per circulatory dynamics.
When caring for a client receiving oxygen therapy, the nurse identifies condensation in the oxygen tubing. What action should the nurse take?
- A. Increase the oxygen flow rate to prevent condensation
- B. Disconnect the tubing and drain the condensation
- C. Replace the oxygen tubing with a new one immediately
- D. Place a heat-moisture exchanger (HME) on the oxygen tubing
Correct Answer: B
Rationale: Disconnecting and draining condensation (B) resolves impedance in oxygen flow from water buildup, maintaining effective delivery. Increasing flow (A) doesn't address it. Replacing tubing (C) is unnecessary if drained. HME (D) is for humidification, not condensation. Draining, per respiratory care, ensures uninterrupted therapy.
When a client wishes to improve the appearance of their eyes by removing excess skin from the face and neck, the nurse should provide teaching regarding which of the following procedures?
- A. Dermabrasion
- B. Rhinoplasty
- C. Blepharoplasty
- D. Rhytidectomy
Correct Answer: D
Rationale: Rhytidectomy (facelift) removes excess skin from face and neck.