Nokea
The nurse is administering mannitol IV to decrease the client’s ICP following a craniotomy. Which laboratory test result should the nurse monitor during the client’s treatment with mannitol?
- A. Serum osmolarity
- B. White blood cell count
- C. Serum cholesterol
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: A
Rationale: Mannitol (Osmitrol), an osmotic diuretic, increases the serum osmolarity and pulls fluid from the tissues, thus decreasing cerebral edema postoperatively. Serum osmolarity levels should be assessed as a parameter to determine proper dosage. The WBC count is not affected by mannitol. Serum cholesterol is not affected by mannitol. ESR is not affected by mannitol.
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Which rationale explains the transmission of the West Nile virus?
- A. Transmission occurs through exchange of body fluids when sneezing and coughing.
- B. Transmission occurs only through mosquito bites and not between humans.
- C. Transmission can occur from human to human in blood products and breast milk.
- D. Transmission occurs with direct contact from the maculopapular rash drainage.
Correct Answer: B
Rationale: West Nile virus is primarily transmitted via mosquito bites (B), not human-to-human contact, body fluids (A), blood/breast milk (C), or rash drainage (D).
The nurse is caring for the client with an SCI at the level of the sixth cervical vertebra. Which findings support the nurse’s conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply.
- A. Blurred vision
- B. BP 198/102 mm Hg
- C. Heart rate 150 bpm
- D. Extreme headache
- E. Sweaty face and arms
Correct Answer: A,B,D,E
Rationale: Blurred vision results from the hypertension occurring with autonomic dysreflexia. Hypertension is a symptom of autonomic dysreflexia from overstimulation of the sympathetic nervous system (SNS). Bradycardia (not tachycardia) results from autonomic dysreflexia; the parasympathetic nervous system attempts to maintain homeostasis by slowing down the HR. Headache results from the hypertension occurring with autonomic dysreflexia. Sweating results from the sympathetic stimulation above the level of injury.
The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement?
- A. Discuss the need to be placed in a long-term care facility.
- B. Explain how to care for a sigmoid colostomy.
- C. Assist the client to prepare an advance directive.
- D. Teach the client how to use a motorized wheelchair.
Correct Answer: C
Rationale: ALS progression leads to significant disability, making advance directives (C) critical to ensure the client’s wishes are respected. Long-term care (A) is premature, colostomy (B) is unrelated, and wheelchair use (D) is secondary.
While awaiting the diagnostic test results for a client with possible meningitis, which transmission-based precautions are the supplement?
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: A
Rationale: Meningitis, especially bacterial, is often transmitted via respiratory droplets, necessitating droplet precautions.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
- A. Feed the 69-year-old client diagnosed with Parkinson’s disease who is having difficulty swallowing.
- B. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson’s disease.
- C. Assist the 54-year-old client diagnosed with Parkinson’s disease with toilet-training activities.
- D. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson’s disease.
Correct Answer: A
Rationale: Feeding a client with swallowing difficulty (A) requires nursing judgment to assess aspiration risk, so it should not be delegated. Turning/positioning (B), assisting with toileting (C), and vital signs (D) are within UAP scope.