Nokea
The nurse has an order for the administration of intravenous heparin. The medication should be administered using a/an:
- A. Metered chamber
- B. Infusion controller
- C. Intravenous filter
- D. Three-way stopcock
Correct Answer: B
Rationale: Intravenous heparin requires precise dosing to maintain therapeutic anticoagulation. An infusion controller (e.g., infusion pump) ensures accurate delivery. A metered chamber is for fluids, an IV filter is for removing particles, and a stopcock is for multiple infusions, not precise control.
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Which set of vital signs would best indicate to the nurse that a client has an increase in intracranial pressure?
- A. BP 180/70, pulse 50, respirations 16, temperature 101°F
- B. BP 100/70, pulse 64, respirations 20, temperature 98.6°F
- C. BP 96/70, pulse 132, respirations 20, temperature 98.6°F
- D. BP 130/80, pulse 50, respirations 18, temperature 99.6°F
Correct Answer: A
Rationale: Increased ICP is indicated by Cushing’s triad: hypertension (BP 180/70), bradycardia (pulse 50), and irregular respirations. Option A best matches this, with fever as a possible secondary sign. Options B, C, and D lack this combination.
The physician has ordered an IV bolus of Solu-Medrol (methylprednisolone sodium succinate) in normal saline for a client admitted with a spinal cord injury. Solu-Medrol has been shown to be effective in:
- A. Preventing spasticity associated with cord injury
- B. Decreasing the need for mechanical ventilation
- C. Improving motor and sensory functioning
- D. Treating post injury urinary tract infections
Correct Answer: C
Rationale: High-dose methylprednisolone within 8 hours of spinal cord injury can improve motor and sensory outcomes by reducing inflammation and edema.
Which nursing interventions are included in the post-operative care of the client following the repair of a retinal detachment with instillation of silicone oil?
- A. Placing the client in a prone position
- B. Maintaining strict bed rest for 24 hours
- C. Offering a clear liquid diet
- D. Instructing the client to keep his head bowed when sitting upright
- E. Applying an eye patch to protect the affected eye from light
Correct Answer: A, D, E
Rationale: Post-retinal detachment with silicone oil requires prone positioning (A) to keep oil against the retina, head bowed when upright (D) to maintain oil placement, and an eye patch (E) to reduce light exposure. Bed rest (B) is not strict, and diet (C) progresses as tolerated.
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
- A. Fluid volume deficit secondary to alteration in skin integrity
- B. Alteration in comfort secondary to alteration in skin integrity
- C. Alteration in sensation secondary to third-degree burn
- D. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
Correct Answer: D
Rationale: Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
- A. Wound culture results showing minimal bacteria
- B. Cloudy, foul-smelling urine
- C. White blood cell count of 14,000/mm3
- D. Temperature elevation of 101°F
Correct Answer: A
Rationale: Minimal bacteria in wound cultures indicates no localized infection, supporting the outcome. Cloudy urine (B), elevated WBC (C), and fever (D) suggest possible infection.