Nokea
The client is undergoing post-thrombolytic therapy for a stroke. The health-care provider has ordered heparin to be infused at 1,000 units per hour. The solution comes as 25,000 units of heparin in 500 mL of D5W. At what rate will the nurse set the pump?
Correct Answer: 20 mL/hr
Rationale: Calculate: (1,000 units/hr ÷ 25,000 units) × 500 mL = 20 mL/hr. The pump should be set to 20 mL/hr.
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Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse’s priority when receiving the client in the ED?
- A. Assessing the client using the Glasgow Coma Scale (GCS)
- B. Assessing the level of sensation in the client’s extremities
- C. Checking that the cervical collar was correctly placed by EMS
- D. Applying antiembolism hose to the client’s lower extremities
Correct Answer: C
Rationale: The nurse should determine the neurological status using the GCS, but this is not the priority. The nurse should assess sensation status at intervals to determine neurological injury progression, but this is not the priority. Maintaining the correct placement of the cervical collar will keep the client’s head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority. Applying antiembolism hose is an intervention to prevent thromboembolic complications, but this is not the priority.
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?
- A. Notify the health-care provider immediately.
- B. Prepare to administer an antihistamine.
- C. Test the drainage for presence of glucose.
- D. Place a 2 x 2 gauze under the nose to collect drainage.
Correct Answer: C
Rationale: Clear nasal drainage post-head injury may indicate cerebrospinal fluid (CSF) leak, confirmed by testing for glucose (C). This is the first step to guide further action. Notifying the provider (A) follows confirmation, antihistamines (B) are irrelevant, and gauze (D) is a secondary measure.
The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?
- A. The elderly client who is experiencing a stroke in evolution.
- B. The client diagnosed with a transient ischemic attack 48 hours ago.
- C. The client diagnosed with Guillain-Barré syndrome who complains of leg pain.
- D. The client with Alzheimer's disease who is wandering in the halls.
Correct Answer: A
Rationale: A stroke in evolution (A) is an acute, progressing condition requiring experienced monitoring. TIA (B) is stable, Guillain-Barré pain (C) is manageable, and wandering (D) needs supervision but is less acute.
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?
- A. Observe the client swallowing for possible aspiration.
- B. Position the client in a semi-Fowler's position when sleeping.
- C. Place a suction setup at the client's bedside during meals.
- D. Refer the client to an occupational therapist for evaluation.
Correct Answer: D
Rationale: Agnosia is the inability to recognize objects, people, or sounds, impacting functional abilities. Referring to an occupational therapist (D) is appropriate to assess and develop strategies for managing agnosia. Swallowing issues (A, C) are related to dysphagia, not agnosia, and semi-Fowler’s position (B) is not specific to agnosia management.
The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home?
- A. The Haemophilus influenzae vaccine.
- B. Antimicrobial chemoprophylaxis.
- C. A 10-day dose pack of corticosteroids.
- D. A gamma globulin injection.
Correct Answer: B
Rationale: Close contacts of meningococcal meningitis patients require antimicrobial chemoprophylaxis (B), such as rifampin, to prevent infection. Vaccines (A) are not for immediate prophylaxis, corticosteroids (C) treat inflammation, and gamma globulin (D) is not indicated.