Nokea
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
- A. Suction the airway.
- B. Hyperoxygenate.
- C. Suction the mouth.
- D. Provide sedation.
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (B); 2) Provide sedation to reduce agitation and ICP spikes (D); 3) Suction the airway to clear secretions (A); 4) Suction the mouth to remove residual secretions (C). This sequence minimizes ICP increases and ensures oxygenation.
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What is a priority nursing intervention for a client with renal colic?
- A. Encourage fluid intake.
- B. Administer morphine as prescribed.
- C. Apply warm compresses.
- D. Insert a urinary catheter.
Correct Answer: B
Rationale: Morphine effectively manages severe renal colic pain, prioritizing client comfort.
The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply.
- A. Nutrition and hydration needs.
- B. Circulation and skin integrity.
- C. Range of motion and positioning.
- D. Behavioral responses and mental status.
Correct Answer: A,B,C,D
Rationale: Documentation must include nutrition/hydration, circulation/skin integrity, range of motion/positioning, and behavioral/mental status to ensure safety and compliance.
After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to:
- A. Monitor for signs and symptoms of hyperthyroidism.
- B. Rest for 1 week to prevent complications of the medication.
- C. Take thyroxine replacement for the remainder of the client's life.
- D. Assess for hypertension and tachycardia resulting from altered thyroid activity.
Correct Answer: C
Rationale: RAI often destroys enough thyroid tissue to cause hypothyroidism, requiring lifelong thyroxine replacement. Monitoring for hyperthyroidism is unnecessary post-treatment, and rest or assessing for hypertension/tachycardia are not primary concerns.
The nurse is caring for a client with a peripherally inserted central catheter (PICC) in the left upper extremity. It would indicate correct nursing care if the nurse
- A. pulsatile flushes each lumen with 0.9% sodium chloride (normal saline) in a 5 mL syringe.
- B. slowly flushes each lumen with 0.9% sodium chloride (normal saline) in a 10 mL syringe.
- C. pulsatile flushes each lumen with sterile water in a 10 mL syringe.
- D. pulsatile flushes each lumen with 0.9% sodium chloride (normal saline) in a 10 mL syringe.
Correct Answer: D
Rationale: PICC lines require pulsatile flushing with 0.9% saline in a 10 mL syringe to maintain patency and prevent occlusion.
A client who is recovering from gastric surgery is receiving I.V. fluids to be infused at 100 mL/hour. The I.V. tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour?
Correct Answer: 25 gtt/minute
Rationale: To calculate: (100 mL/hour × 15 gtt/mL) ÷ 60 minutes/hour = 25 gtt/minute. The nurse should set the flow rate to 25 drops per minute.