Nokea
Following a craniotomy, why did the nurse position the client in low Fowler's position?
- A. To promote comfort.
- B. To promote drainage from the operation site.
- C. To promote thoracic expansion.
- D. To prevent circulatory overload.
Correct Answer: B
Rationale: Positioning the client in low Fowler's position after a craniotomy is essential to promote drainage from the operation site. This position helps prevent fluid accumulation, facilitates the removal of excess fluid or blood, and aids in the healing process. Choice A is incorrect because comfort, while important, is not the primary reason for this specific positioning. Choice C is incorrect as thoracic expansion is not the main concern following a craniotomy. Choice D is incorrect as circulatory overload is not typically addressed by positioning in low Fowler's position post-craniotomy.
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An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper, and skin breakdown is obvious over his sacral area. What action should the nurse implement first?
- A. Establish a toileting schedule to decrease episodes of incontinence
- B. Complete a functional assessment of the client's self-care abilities
- C. Apply a barrier ointment to intact areas that may be exposed to moisture
- D. Determine the size and depth of skin breakdown over the sacral area
Correct Answer: D
Rationale: The initial step the nurse should take when faced with skin breakdown over the sacral area of the client is to determine the size and depth of the affected area. Assessing and documenting these aspects are crucial before initiating any treatment. This evaluation will guide the nurse in developing an appropriate care plan to address the skin breakdown effectively. Options A, B, and C are not the first steps to take in this situation. While establishing a toileting schedule and completing a functional assessment are important, assessing the size and depth of the skin breakdown is the priority to initiate proper treatment. Applying a barrier ointment without assessing the extent of the breakdown may not address the underlying issue effectively.
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?
- A. Perform range-of-motion exercises to prevent contractures.
- B. Decrease the client's fluid intake to prevent diarrhea.
- C. Massage the client's legs to reduce the occurrence of embolisms.
- D. Turn the client from side to back every shift.
Correct Answer: A
Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.
A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?
- A. Use distraction techniques during times of spiritual stress and crisis.
- B. Reassure the client that their faith will be regained with time and support.
- C. Consult with the staff chaplain and request that the chaplain visit with the client.
- D. Use reflective listening techniques when the client expresses spiritual doubts.
Correct Answer: D
Rationale: When a client is going through spiritual distress, employing reflective listening techniques is crucial. This method allows the client to voice their concerns and emotions, providing them with a supportive environment to explore their feelings. Options A and B do not directly address the client's spiritual distress and may undermine the client's feelings. While option C involves a chaplain, using reflective listening directly involves the nurse in addressing and supporting the client's spiritual concerns.
The healthcare professional is monitoring a client receiving IV potassium chloride. Which assessment finding should prompt the healthcare professional to immediately stop the infusion?
- A. The client reports pain at the IV site
- B. The client's heart rate is irregular
- C. The client has swelling at the IV site
- D. The client's blood pressure is elevated
Correct Answer: B
Rationale: An irregular heart rate is a critical sign of hyperkalemia, a serious condition that can lead to life-threatening cardiac arrhythmias. Stopping the infusion promptly is crucial to prevent further complications. The healthcare professional should inform the healthcare provider immediately for further evaluation and management. Choice A is incorrect because pain at the IV site is common and may not necessitate stopping the infusion. Choice C is incorrect as swelling at the IV site may indicate a local reaction but is not a reason to stop the infusion. Choice D is incorrect as an elevated blood pressure alone is not a direct indication to stop the infusion of IV potassium chloride.
What is the most important action for the nurse to take when caring for a client with a spinal cord injury experiencing autonomic dysreflexia?
- A. Elevate the head of the bed to 45 degrees.
- B. Monitor the client's respiratory rate.
- C. Administer an antihypertensive medication.
- D. Assess the client's blood glucose level.
Correct Answer: A
Rationale: In a client with autonomic dysreflexia, the most critical action is to elevate the head of the bed to 45 degrees (A). This positioning helps reduce blood pressure, which is essential in managing autonomic dysreflexia. Monitoring the client's respiratory rate (B) is important for overall assessment but not the priority in this situation. Administering an antihypertensive medication (C) without addressing the positioning issue first can lead to further complications. Assessing the client's blood glucose level (D) is not directly related to autonomic dysreflexia and is not the initial priority in this scenario.