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 dangerously high (normal <20 mmHg), requiring immediate physician notification for intervention. Recording only (B), turning (C), or supine positioning (D) delays critical action.
You may also like to solve these questions
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Hemolytic transfusion reaction
- B. Febrile transfusion reaction
- C. Circulatory overload
- D. Allergic transfusion reaction
Correct Answer: D
Rationale: A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. Fever, chills, and headaches are indicative of a febrile transfusion reaction. Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
The client is admitted with a diagnosis of acute diverticulitis. Which dietary order should the nurse anticipate?
- A. High-fiber diet
- B. Low-residue diet
- C. Clear liquid diet
- D. Regular diet
Correct Answer: C
Rationale: A clear liquid diet is ordered during acute diverticulitis to rest the bowel and reduce irritation. High-fiber is for prevention, low-residue is for chronic management, and regular diets are inappropriate.
The client is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate notification of the physician?
- A. Blood pressure of 140/90
- B. 2+ proteinuria
- C. Headache and visual disturbances
- D. Edema of the hands
Correct Answer: C
Rationale: Headache and visual disturbances in gestational hypertension suggest severe preeclampsia or impending eclampsia requiring immediate physician notification. BP of 140/90 proteinuria and edema are concerning but less urgent unless severe.
The nurse is caring for a client with a tracheostomy. Which action is a priority during tracheostomy care?
- A. Clean the inner cannula with sterile technique.
- B. Apply a dry dressing to the tracheostomy site.
- C. Suction the tracheostomy after cleaning.
- D. Change the tracheostomy ties daily.
Correct Answer: A
Rationale: Cleaning the inner cannula with sterile technique prevents infection and maintains airway patency, a priority. Dressings (B), suctioning (C), and tie changes (D) are secondary.
Chorioamnionitis is a maternal infection that is usually associated with:
- A. Prolonged rupture of membranes
- B. Postterm deliveries
- C. Maternal pyelonephritis
- D. Maternal dehydration
Correct Answer: A
Rationale: Chorioamnionitis is an inflammation of the chorion and amnion that is generally associated with premature or prolonged rupture of membranes.