Nokea
The intensive care nurse is caring for the client who has had intracranial surgery. Which interventions should the nurse implement? Select all that apply.
- A. Assess for deep vein thrombosis.
- B. Administer intravenous anticoagulant.
- C. Monitor intake and output strictly.
- D. Apply warm compresses to the eyes.
- E. Perform passive range-of-motion exercises.
Correct Answer: A,C,E
Rationale: Assessing DVT (A), monitoring intake/output (C), and passive ROM (E) prevent complications. Anticoagulants (B) increase bleeding risk, and warm compresses (D) are not indicated.
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The client is diagnosed with a metastatic brain tumor, and radiation therapy is scheduled. The client asks the nurse, 'Why not try chemotherapy first? It has helped my other tumors.' The nurse’s response is based on which scientific rationale?
- A. Chemotherapy is only used as a last resort in caring for clients with brain tumors.
- B. The blood-brain barrier prevents medications from reaching the brain.
- C. Radiation therapy will have fewer side effects than chemotherapy.
- D. Metastatic tumors become resistant to chemotherapy and it becomes useless.
Correct Answer: B
Rationale: The blood-brain barrier (B) limits chemotherapy penetration into the brain, making radiation more effective for brain metastases. Chemotherapy is used in some cases (A), radiation side effects vary (C), and resistance (D) is not universally true.
When the client is observed wandering about the facility, the nurse modifies the client's care plan to provide for safety. Which nursing intervention is most appropriate at this time?
- A. Keep the client confined to the room.
- B. Attach an identity tag to the client's clothes.
- C. Lock all the outside doors in the facility.
- D. Make sure the client knows the location of the facility.
Correct Answer: B
Rationale: An identity tag helps ensure the client can be identified and returned safely if they wander, promoting safety without restricting freedom.
The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement?
- A. Keep oxygen via nasal cannula on at all times.
- B. Administer low-dose subcutaneous anticoagulants.
- C. Perform active lower extremity ROM exercises.
- D. Refer to a speech therapist for ventilator-assisted speech.
Correct Answer: B
Rationale: Lumbar SCI affects lower extremities, increasing DVT risk. Low-dose anticoagulants (B) prevent thromboembolism. Oxygen (A) is unnecessary without respiratory issues, active ROM (C) is not feasible due to paralysis, and speech therapy (D) is irrelevant.
The public health department nurse is preparing a lecture on prevention of West Nile virus. Which information should the nurse include?
- A. Change water daily in pet dishes and birdbaths.
- B. Wear thick, dark clothing when outside to avoid bites.
- C. Apply insect repellent over face and arms only.
- D. Explain that mosquitoes are more prevalent in the morning.
Correct Answer: A
Rationale: Changing water daily in pet dishes and birdbaths (A) prevents mosquito breeding, reducing West Nile virus risk. Thick clothing (B) should be light-colored, repellent (C) should cover all exposed areas, and mosquitoes are more active at dusk (D).
Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel?
- A. Teach Credé’s maneuver to the client needing to void.
- B. Administer the tube feeding to the client who is quadriplegic.
- C. Assist with bowel training by placing the client on the bedside commode.
- D. Observe the client demonstrating self-catheterization technique.
Correct Answer: C
Rationale: Assisting with bowel training by placing the client on a commode (C) is within the UAP’s scope, involving physical assistance. Teaching (A), administering tube feedings (B), and observing techniques (D) require nursing judgment and are not delegable.