Nokea
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician
- B. Record the reading as the only action
- C. Turn the client and recheck the reading
- D. Place the client supine
Correct Answer: A
Rationale: An ICP of 66 mmHg is critically high (normal <20 mmHg), indicating severe brain swelling. Notifying the physician is urgent for immediate intervention.
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The nurse is caring for a client who is 14 weeks pregnant. The client is asking about vaccinations that can be given during pregnancy. Which of the following vaccines does the nurse tell the client that are safe during pregnancy?
- A. mumps
- B. measles
- C. smallpox
- D. influenza
Correct Answer: D
Rationale: The influenza vaccine is safe and recommended during pregnancy. Mumps, measles, and smallpox vaccines are contraindicated.
During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse's first action should be to:
- A. Notify the hospital pharmacist
- B. Notify the nursing supervisor
- C. Notify the Board of Nursing
- D. Notify the director of nursing
Correct Answer: B
Rationale: A narcotic discrepancy requires reporting to the supervisor for investigation.
The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus. The client has been maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past two days were 205 mg/dL and 233 mg/dL. The nurse expects the physician to
- A. reduce the client’s diet to 1,500 calorie ADA.
- B. order 3 additional units of NPH insulin at 10 PM.
- C. order an additional 10 units of regular insulin at 8 PM.
- D. eliminate the client’s bedtime snack.
Correct Answer: B
Rationale: dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia
A client who has been taking Coumadin (warfarin) was stabbed in the upper arm. His prothrombin time is over twice the normal amount. The nurse anticipates an order for
- A. fresh frozen plasma
- B. whole blood
- C. platelets
- D. packed red blood cells
Correct Answer: A
Rationale: Elevated prothrombin time indicates excessive anticoagulation. Fresh frozen plasma provides clotting factors to reverse warfarin’s effect and control bleeding.
The nurse is preparing to discharge a client who is taking an MAOI. The nurse should instruct the client to:
- A. Wear protective clothing and sunglasses when outside
- B. Avoid over-the-counter cold and hayfever preparations
- C. Drink at least eight glasses of water a day
- D. Increase his intake of high-quality protein
Correct Answer: B
Rationale: MAOIs interact dangerously with OTC cold and hayfever medications containing sympathomimetics, risking hypertensive crisis.