Nokea
The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse?
- A. I will raise the head of the bed so it is easier to see the television.
- B. I will turn down the lights when I leave.
- C. Let me move your belongings closer so you can reach them
- D. You should do deep breathing and coughing exercises.
Correct Answer: A
Rationale: Raising the head of the bed (A) without medical guidance can alter ICP dangerously. Dimming lights (B), moving belongings (C), and breathing exercises (D) are generally safe or neutral.
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The nurse is caring for a 12-month-old client who is HIV-positive and severely immunosuppressed. Which of the following scheduled immunizations should the nurse anticipate administering to the client? Select all that apply.
- A. Haemophilus influenzae type b
- B. Hepatitis A
- C. Measles, mumps, rubella
- D. Pneumococcal conjugate vaccine
- E. Varicella
Correct Answer: A,D
Rationale: Hib (A) and PCV (D) are inactivated vaccines, safe for immunosuppressed children. MMR (C) and varicella (E) are live vaccines, contraindicated. Hepatitis A (B) is not routine at 12 months.
The nurse is preparing to irrigate the wound of a 7-year-old client who sustained a laceration while on a playground. Which of the following actions should the nurse take? Select all that apply.
- A. Administer a prescribed analgesic 30 minutes before irrigating the wound
- B. Cleanse the wound from the most contaminated to the least contaminated area
- C. Obtain a 10-mL syringe and a 27-gauge needle
- D. Review the client's vaccination record
- E. Use continuous pressure to flush the wound and repeat until the drainage is clear
Correct Answer: A,D,E
Rationale: Analgesics (A), checking vaccinations (D) for tetanus risk, and continuous flushing (E) are appropriate. Cleaning from contaminated to clean (B) is incorrect, and a 27-gauge needle (C) is too small for irrigation.
The nurse is monitoring a client who had an esophagogastroduodenoscopy 2 hours ago. Which finding requires an immediate report to the registered nurse?
- A. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg
- B. Gag reflex has not returned
- C. Sore throat when swallowing
- D. Temperature spike to 101.2 F (38.4 C)
Correct Answer: D
Rationale: A temperature spike to 101.2 F (D) suggests possible perforation or infection, requiring immediate reporting. BP drop (A) is mild, absent gag reflex (B) is expected, and sore throat (C) is normal post-procedure.
The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?
- A. My pain is deep in my chest behind my breast bone.
- B. When I sit up the pain gets worse.
- C. As I take a deep breath the pain gets worse.
- D. The pain is right here in my stomach area.
Correct Answer: A
Rationale: My pain is deep in my chest behind my breast bone. This describes the typical substernal pain of acute angina.
Which of the following nursing interventions is essential when caring for a client who is receiving Cyclophosphamide (Cytoxin)?
- A. Monitoring vital signs q 1 hour
- B. Carefully monitoring of urine output
- C. Monitoring apical pulse
- D. Assessing for signs of increased intracranial pressure
Correct Answer: B
Rationale: Cyclophosphamide can cause hemorrhagic cystitis; monitoring urine output is critical to detect blood in the urine and ensure adequate hydration.