Nokea
A nurse is caring for a patient in the step down unit. The patient has signs of increased intracranial pressure. Which of the following is not a sign of increased intracranial pressure?
- A. Bradycardia
- B. Increased pupil size bilaterally
- C. Change in LOC
- D. Vomiting
Correct Answer: B
Rationale: Unilateral pupil changes indicate changes in ICP.
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When performing an abdominal assessment, what is the correct order of the tasks?
- A. inspect, percuss, palpate, auscultate
- B. inspect, palpate, percuss, auscultate
- C. inspect, auscultate, percuss, palpate
- D. inspect, palpate, auscultate, percuss
Correct Answer: C
Rationale: In an abdominal assessment, percussing or palpating prior to auscultating can alter the bowel sounds and influence findings.
A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
- A. Measure intake and output
- B. Check albumin level
- C. Monitor glucose levels
- D. Increase enteral feeding
Correct Answer: A
Rationale: Measuring intake and output assesses fluid balance, critical in enteral feeding to prevent dehydration or fluid overload due to hyperosmotic feedings.
Which of these does not need to be included when calculating a client's fluid intake?
- A. ice chips
- B. Jell-O™
- C. pudding
- D. IV fluid from an antibiotic piggyback
Correct Answer: C
Rationale: Pudding is a semi-solid and does not melt at room temperature, so it should not be included in fluid intake calculations.
The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
- A. Pureed canned squash
- B. Pureed apples
- C. Yogurt
- D. Infant rice cereal
Correct Answer: D
Rationale: Infant rice cereal is recommended as a first solid food due to its digestibility and added iron, suitable for infants starting solids.
The nurse is observing the UAP providing oral hygiene to the client Which action by the UAP requires follow-up?
- A. Replacing the upper denture before the lower denture.
- B. Placing the unconscious client in a supine position.
- C. Brushing the tongue with a soft-bristled toothbrush.
- D. Donning clean gloves prior to performing oral hygiene.
Correct Answer: B
Rationale: B: The unconscious client should be placed in a side-lying position with the head turned to the side to prevent aspiration. A: Replacing the upper denture first is correct for ease of insertion. C: Brushing the tongue removes debris, reducing infection risk. D: Gloves adhere to standard precautions for oral care.