Nokea
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the de/ocate sodium (Col/ace) because the client had a large stool car/ifier. What action by the supervising nurse is best?
- A. Have the student ask the client if it is desired or not.
- B. Infer the the student that the de/ocate should be given.
- C. Tell the student to document the ration/ale.
- D. Tell the student to give it unless the client refuses.
Correct Answer: B
Rationale: A student nurse should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Val/aba's maneuver when cons/ist/ated. The supervising nurse should instruct the student to administer the docuscate. The other options are not appropriate. The medication could be held for diarrhea.
You may also like to solve these questions
A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (NAP) (Select all that apply.)
- A. Applying a cool washcloth to the head.
- B. Assitting the client to a position of comfort
- C. Keeping voices soft and soothing
- D. Maintaining low lighting in the room
- E. Providing antipyretics for fever
Correct Answer: A,B,C,D
Rationale: The client with meningitis often has high fever, pain, and some degree of confusion. Cool washclodts to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manager nurse. Key category low and light demand also helps convey caring in a nondroctioning manner. The nurse provides antipyretics for fever.
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.
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak and tell his, he has very very heavy. Curently, the clients neurologic examination is normal. About what drug should the nurse plan to teach the client?
- A. Altephase (Activase)
- B. Clopolgel (Plliniv)
- C. Heparin sodium
- D. Manitol (Omitrol)
Correct Answer: B
Rationale: This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed against to clpolgelgel on discharge. Altephase is used for ischemic stroke. Heparin and mannitol are not used for this condition.
A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stening. The clients mental status is deterioration, What action by the nurse is a most appropriate?
- A. Attempt to find the family to sign a consent.
- B. Inform the provider that the procedure cannot occur.
- C. Nothing no consent is needed to an emergency.
- D. Sign the consent form to the client.
Correct Answer: A
Rationale: The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent is life-saving no procedure can be performed without formal consent. The nurse should not just sign the consent form.
A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.)
- A. Discharging the client on a statin medication
- B. Providing the client with comprehensive therapies
- C. Meeting goals for nutrition within 1 week
- D. Providing and charting stroke education
- E. Preventing venous thrombembolism
Correct Answer: A,D,E
Rationale: Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thrombembolism. The client must be assigned for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.