Nokea
The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate?
- A. The head of the bed elevated 30 to 45 degrees.
- B. Trendelenburg's position.
- C. Left Sims position.
- D. The head elevated on two pillows.
Correct Answer: A
Rationale: Elevating the head of the bed 30 to 45 degrees promotes venous drainage from the brain, reducing ICP. Trendelenburg's position increases ICP by impeding venous return, Sims position is unrelated to ICP management, and pillows may not ensure consistent elevation or neutral neck alignment.
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The nurse is monitoring a client post-insertion of a nasogastric tube for an intestinal obstruction. Which finding indicates the tube is functioning correctly?
- A. Clear, watery output.
- B. Bright red blood in the drainage.
- C. No output for 12 hours.
- D. Thick, mucus-like drainage.
Correct Answer: A
Rationale: Clear, watery output from a nasogastric tube indicates it is effectively decompressing the intestine by removing fluid and gas. Bright red blood suggests bleeding, no output may indicate a blockage, and thick drainage is not typical. CN: Physiological adaptation; CL: Evaluate
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.
Which intervention is most appropriate for a client with impaired mobility due to a neurological condition?
- A. Encourage bed rest.
- B. Provide assistive devices.
- C. Limit physical therapy.
- D. Restrict fluid intake.
Correct Answer: B
Rationale: Providing assistive devices promotes safe mobility and independence for a client with impaired mobility.
A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?
- A. Stabilize the leg with Buck's traction.
- B. Apply an ice pack to the affected hip.
- C. Position the client toward the opposite side of the hip.
- D. Notify the orthopedic surgeon.
Correct Answer: D
Rationale: Notifying the surgeon is the priority, as dislocation requires urgent medical intervention.
The nurse reviews laboratory data for a client with human immunodeficiency virus (HIV) and notes an increased viral load (VL). The nurse reviews the client's current medications and should clarify which medication with the primary healthcare provider (PHCP)?
- A. Acetaminophen
- B. Echinacea
- C. Cetirizine
- D. Calcium carbonate
Correct Answer: B
Rationale: Echinacea, an herbal supplement, may interfere with antiretroviral therapy for HIV, potentially reducing its effectiveness and leading to an increased viral load. Choices A (acetaminophen), C (cetirizine), and D (calcium carbonate) do not have known interactions that significantly impact HIV viral load.