Nokea
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client?
- A. Keeping the client flat on one side or the other.
- B. Elevating the head of the bed to 30 degrees.
- C. Logrolling or turning as a unit when turning.
- D. Keeping the neck in a neutral position.
Correct Answer: A
Rationale: Keeping the client flat is contraindicated after a posterior fossa craniotomy, as it increases ICP. Elevating the head, logrolling, and neutral neck positioning promote venous drainage and spinal alignment, reducing ICP risk.
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The nurse is teaching an older adult client with a history of heat exhaustion. Which of the following statements by the client indicates a need for further teaching?
- A. I should take a cool shower after being outdoors in very hot weather.
- B. I can place ice packs on my neck, chest, and stomach after being outdoors in the heat.
- C. I should wear lightweight, light-colored, and loose-fitting clothing when working outside on very hot days.
- D. I should consume water and take my salt tablets when I am outside gardening on very hot days.
Correct Answer: B
Rationale: Using ice packs can cause vasoconstriction or tissue damage and is not recommended for heat exhaustion. Cool showers (A), appropriate clothing (C), and hydration (D) are correct, but salt tablets are unnecessary with adequate diet and hydration.
A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived, shown below. Which finding should the nurse report to the physician?
- A. PaCO2.
- B. HCO3.
- C. PaO2.
- D. pH
Correct Answer: A
Rationale: The normal range for partial pressure of arterial carbon dioxide (PaCO2) is 35 to 45 mm Hg. Thus, this client’s PaCO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid defi cit) due to hyperventilation. The nurse should report this fi nding to the physician because it requires intervention. The increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is greater than 7.45.
The nurse is assessing a client with drooping of their left eyelid. The nurse documents this finding as
- A. mydriasis.
- B. ptosis.
- C. presbyopia.
- D. hyphema.
Correct Answer: B
Rationale: Ptosis is the medical term for drooping of the eyelid. Mydriasis refers to pupil dilation, presbyopia is age-related vision loss, and hyphema is blood in the anterior chamber of the eye.
The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should:
- A. Pour the solution over ice chips.
- B. Mix the solution with an antacid.
- C. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw.
- D. Disguise the solution in a pureed fruit or vegetable.
Correct Answer: C
Rationale: SSKI has an unpleasant taste and can stain teeth. Diluting it with water, milk, or juice and using a straw minimizes discomfort and staining.
A client with ulcerative colitis is prescribed mesalamine (Asacol). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Slight rash.
- C. Worsening diarrhea.
- D. Fatigue.
Correct Answer: C
Rationale: Worsening diarrhea in a client with ulcerative colitis taking mesalamine may indicate a lack of therapeutic response or a serious adverse effect, requiring immediate reporting. Mild headache, slight rash, and fatigue are less urgent but should be monitored. CN: Pharmacological and parenteral therapies; CL: Synthesize