Nokea
During the immediate postoperative assessment, the nurse notices the dressing is moist. Which action is most appropriate to take first?
- A. Change the dressing.
- B. Reinforce the dressing.
- C. Remove the dressing.
- D. Document the findings.
Correct Answer: B
Rationale: Reinforcing the dressing controls minor drainage and maintains sterility while further assessment is conducted.
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The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
- A. Institute aspiration precautions.
- B. Refer the client to Reach to Recovery.
- C. Initiate seizure precautions.
- D. Teach the client about mastectomy care.
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (C) are appropriate. Aspiration precautions (A) are unrelated, Reach to Recovery (B) supports breast cancer recovery, and mastectomy care (D) is not relevant to brain metastases.
Which client response depicts normal function of cranial nerve XI?
- A. A client wrinkling the forehead
- B. A client puffing out the cheeks
- C. A client sticking out the tongue
- D. A client shrugging the shoulders
Correct Answer: D
Rationale: Cranial nerve XI (spinal accessory) innervates the trapezius and sternocleidomastoid muscles, enabling shoulder shrugging.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
- A. Maintain the head of the bed at 60 degrees of elevation.
- B. Administer stool softeners daily.
- C. Ensure the pulse oximeter reading is higher than 93%.
- D. Perform deep nasal suction every two (2) hours.
- E. Administer mild sedatives.
Correct Answer: B,C
Rationale: Stool softeners (B) prevent straining, which could increase ICP. Maintaining pulse oximetry >93% (C) ensures adequate oxygenation. High HOB elevation (A) may reduce cerebral perfusion, deep suction (D) risks increasing ICP, and sedatives (E) may mask neurological changes.
The nurse is caring for clients on a medical unit. Which client would be most at risk for experiencing a stroke?
- A. A 92-year-old client who is an alcoholic.
- B. A 54-year-old client diagnosed with hepatitis.
- C. A 60-year-old client who has a Greenfield filter.
- D. A 68-year-old client with chronic atrial fibrillation.
Correct Answer: D
Rationale: Atrial fibrillation (D) increases stroke risk due to clot formation. Age (A) is a factor but less specific, hepatitis (B) is unrelated, and Greenfield filters (C) prevent pulmonary embolism, not stroke.
The nurse is administering mannitol IV to decrease the client’s ICP following a craniotomy. Which laboratory test result should the nurse monitor during the client’s treatment with mannitol?
- A. Serum osmolarity
- B. White blood cell count
- C. Serum cholesterol
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: A
Rationale: Mannitol (Osmitrol), an osmotic diuretic, increases the serum osmolarity and pulls fluid from the tissues, thus decreasing cerebral edema postoperatively. Serum osmolarity levels should be assessed as a parameter to determine proper dosage. The WBC count is not affected by mannitol. Serum cholesterol is not affected by mannitol. ESR is not affected by mannitol.