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An ICU nurse monitors a client recovering from a head injury. The client's intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client's endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
- A. increase the rate of the sedative IV drip.
- B. chart the findings and continue to monitor the client.
- C. reposition the client.
- D. contact the physician.
Correct Answer: D
Rationale: A sudden ICP spike to 28 mmHg post-suctioning suggests a significant issue (e.g., impaired cerebral perfusion). The physician should be contacted for evaluation.
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The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for:
- A. Peaked P wave
- B. Elevated ST segment
- C. Inverted T wave
- D. Prolonged QT interval
Correct Answer: D
Rationale: Quinidine can prolong the QT interval, increasing the risk of torsades de pointes.
The nurse is caring for a client admitted to ICU following a heart attack. The nurse notes on the chart that the client has named his spouse to make decisions regarding his care if he is unable to speak for himself. What is the name of the document the client has signed? Fill in the blank.
- A. Living Will
- B. Do Not Resuscitate Order
- C. Durable Power of Attorney for Healthcare
- D. Advance Directive
Correct Answer: C
Rationale: The document is a **Durable Power of Attorney for Healthcare** or **Healthcare Proxy**, designating the spouse as the decision-maker.
Which of the following groups of neonates should be screened for hearing loss?
- A. Premature neonates.
- B. Neonates with risk factors for hearing loss.
- C. Neonates with abnormal Apgar scores.
- D. All neonates.
Correct Answer: D
Rationale: Universal newborn hearing screening is recommended for all neonates (D) to detect hearing loss early. Premature neonates (A), those with risk factors (B), or abnormal Apgar scores (C) are included but not exclusive.
The primary cause of anemia in a client with chronic renal failure is:
- A. Poor iron absorption
- B. Destruction of red blood cells
- C. Lack of intrinsic factor
- D. Insufficient erythropoietin
Correct Answer: D
Rationale: Chronic renal failure reduces erythropoietin production by the kidneys, leading to decreased red blood cell production and anemia.
A nurse must teach a client how to do wound care and dressing changes prior to discharge. Which of the following are barriers to learning? Select all that apply.
- A. The client is 55 years old.
- B. The client is fearful.
- C. The client is illiterate.
- D. The client is weak and frail.
- E. The client has many questions about the procedures.
- F. The client is hard of hearing.
Correct Answer: B,C,F
Rationale: Barriers to learning include fear (B), which can hinder concentration; illiteracy (C), which affects understanding written instructions; and hearing impairment (F), which impedes verbal communication. Age 55 (A), weakness (D), and asking questions (E) are not barriers.