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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.
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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.
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 nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.)
- A. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence.
- B. Client who had a cool procedure who says that there will be no problem following up for 1 year.
- C. Client who underwent a flow diversion procedure 3 months ago who is taking discontinue sodium (Colace) for constipation.
- D. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise
Correct Answer: A,B
Rationale: After a coil procedure, up to 20% of clients experience re-beding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.
A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activity (t-PA) alphaing (Activase). The client weight is 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) mg
- A. 90 mg
- B. 100 mg
- C. 80 mg
- D. 110 mg
Correct Answer: A
Rationale: The client weighs 146 pounds, which is approximately 66.2 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg. Therefore, 0.9 mg/kg ? 66.2 kg = 59.58 mg, which is less than the maximum dose of 90 mg. Thus, the client will receive 90 mg.
A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?
- A. Client with a core temperature of 95 F (35 C) for 2 days
- B. Client is a core for 2 weeks from a motor/ vehicle crash
- C. Client who is found unresponsive in a remote area of a field by a hunter
- D. Client with a systole blood/ pressure of 92 mm Hg since admission
Correct Answer: B
Rationale: In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near normal core temperature, 3) normal systolic blood pressure, and 4) a least one mentioned assessment. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client who is found unresponsive.