Nokea
The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by reversing dilation of cerebral blood vessels. Which physician prescription would the nurse expect to accomplish this?
- A. Hyperventilation per mechanical ventilation
- B. Insertion of a ventricular shunt
- C. Furosemide (Lasix)
- D. Methylprednisolone (Solu-Medrol)
Correct Answer: A
Rationale: Hyperventilation is utilized to decrease the PCO2 to 27-30, producing cerebral blood vessel constriction. Answers B, C, and D can decrease cerebral edema, but not by constriction of cerebral blood vessels; therefore, they are wrong.
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A client with cancer pain is prescribed oxycodone. Which information is most essential to reinforce in order to help prevent long-term complications?
- A. How to monitor blood pressure daily
- B. How to prevent constipation
- C. How to prevent itching
- D. How to prevent nausea
Correct Answer: B
Rationale: Constipation is a common, long-term complication of oxycodone, requiring preventive measures like fiber and fluids. Blood pressure monitoring, itching, and nausea are less critical long-term concerns.
A 2-year-old child seen in the emergency department is dehydrated and malnourished. The child’s parent reports that the child has had diarrhea for the past 2 weeks. Which observation is of most concern to the nurse?
- A. The parent cannot stay at the hospital due to potential job loss if late for work
- B. The parent does not seem to be concerned about the child’s condition
- C. The parent is single
- D. The parent left a 3-year-old and a 5-year-old in the care of a 9-year-old
Correct Answer: D
Rationale: Leaving young children in the care of a 9-year-old poses significant safety risks, indicating neglect and requiring immediate intervention. Job constraints, lack of concern, and single status are concerning but less immediately dangerous.
Exhibit 1
Vital signs
0800
Temperature 98.4 F (36.8 C)
Blood pressure 110/72 mm Hg
Heart rate 52/min
Respirations 16/min
Exhibit 2
Laboratory results
0800
Hematocrit
Male: 42%–52%
(0.42-0.52)
Female: 37%–47%
(0.37–0.47) 40%
(0.4)
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)
Female: 12.0–16.0 g/dL
(120–160 g/L) 14.0 g/dL
(140 g/L)
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 200,000/mm3
(200 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 4.0 mEq/L
(4.0 mmol/L)
Exhibit 3
Medication administration record
Allergies: No known drug allergies
Medications Time
Aspirin: 81 mg by mouth, daily 0900
Docusate sodium: 100 mg by mouth, daily 0900
Lisinopril: 5 mg by mouth, daily 0900
Metoprolol: 100 mg by mouth, twice daily 0900, 1700
Simvastatin: 20 mg by mouth, daily 2000
A client with ST segment elevation myocardial infarction is due for 0900 medications. Based on the data shown in the exhibit, which medications should the nurse administer? Select all that apply.
- A. aspirin
- B. docusate sodium
- C. lisinopril
- D. metoprolol
- E. simvastatin
Correct Answer: A,C,D,E
Rationale: Aspirin (antiplatelet), lisinopril (ACE inhibitor), metoprolol (beta-blocker), and simvastatin (statin) are standard for STEMI to reduce clot formation, blood pressure, and cholesterol. Docusate is unrelated to STEMI management.
An adult woman who broke her right ankle is seen in the physician's office one week after the cast was applied. Which observation indicates to the office nurse that the client is using crutches correctly?
- A. The client moves the left crutch forward, then the right foot, then the right crutch, and finally the left foot.
- B. The client moves the left crutch and the right foot together, and then moves the right crutch and the left foot together.
- C. The client moves the left foot and the crutches forward while bearing weight on the right foot.
- D. The client bears weight on the left foot, and then moves the right foot and the crutches forward.
Correct Answer: A
Rationale: The four-point crutch gait (left crutch, right foot, right crutch, left foot) is stable and correct for a non-weight-bearing right ankle, ensuring balance and safety.
During morning rounds, the nurse notices that a client who was admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.
- A. Compare current mental status to previous findings
- B. Encourage the client to ambulate in the hallway
- C. Hold the client's morning dose of lactulose
- D. Monitor the client's ammonia level
- E. Observe the client's hand movements with the arms extended
Correct Answer: A,D,E
Rationale: Comparing mental status, monitoring ammonia, and observing for asterixis (hand flapping) assess worsening encephalopathy, delaying discharge. Ambulation is unsafe, and holding lactulose may worsen symptoms.