Nokea
The nurse is caring for a client with suspected meningitis. Which priority action should the nurse take following a lumbar puncture (LP) procedure?
- A. Assess the gag reflex
- B. Elevate the head of the bed to 30 degrees
- C. Encourage oral fluid intake
- D. Assess the client for Brudzinski sign
Correct Answer: C
Rationale: Encouraging oral fluid intake (C) post-lumbar puncture helps prevent spinal headache and supports recovery. Assessing gag reflex (A) is unrelated, elevating the head (B) depends on provider orders, and Brudzinski’s sign (D) is assessed before the procedure to diagnose meningitis, not after.
You may also like to solve these questions
The nurse working on a medical-surgical unit is caring for assigned clients. The nurse should plan to initially assess the client who
- A. had a subtotal thyroidectomy 12 hours ago and reports difficulty swallowing.
- B. reports increased pain following a sterile dressing change for a stage IV pressure ulcer.
- C. has bilateral lower lobe pneumonia and has not used the incentive spirometer in six hours.
- D. is scheduled for an adrenalectomy in eight hours and has not signed the informed consent.
Correct Answer: A
Rationale: Difficulty swallowing post-thyroidectomy (A suggests complications like hematoma or nerve injury, which can be life-threatening and require immediate assessment. Increased pain (B), and not using an incentive spirometer (C), and lack of consent (D) are less urgent and critical.
The nurse is teaching a group of students about incident reports. Which of the following situations would require an incident report? A visitor. Select all that apply.
- A. refusing to wear personal protective equipment (PPE).
- B. adjusting a client's infusion pump.
- C. requesting that their family member get pain medication.
- D. assisting their family member with brushing their teeth.
- E. stating that they fell while using the bathroom.
Correct Answer: A, B, E
Rationale: Refusing PPE (A), adjusting an infusion pump (B), and falling in the bathroom (E) are safety incidents requiring reports, as they pose risks or indicate harm. Requesting pain medication (C) and assisting with tooth brushing (D) are not reportable unless escalated.
The nurse is caring for a client admitted for an exacerbation of Meniere’s disease. Which of the following nursing interventions is of the highest priority when caring for this client?
- A. Determining if the client has experienced hearing loss.
- B. Initiating fall risk measures.
- C. Ensuring adherence to a low-sodium diet.
- D. Administering prescribed anticholinergic medications.
Correct Answer: B
Rationale: Initiating fall risk measures (B) is the highest priority in Meniere’s exacerbation due to vertigo, which poses an immediate safety risk. Hearing loss assessment (A), low-sodium diet (C), and medications (D) are important but secondary to preventing falls.
The nurse reviews the client's emergency department (ED) triage note. Which action should the nurse take first? See the image below.
- A. Establish continuous cardiac monitoring
- B. Obtain an order for a complete metabolic panel
- C. Obtain a prescription for acetaminophen (APAP)
- D. Apply a cool compress to the client's forehead
Correct Answer: A
Rationale: This client is showing manifestations of digitalis toxicity. The client's bradycardia, anorexia, and vomiting are classic signs of this potentially fatal toxicity. The nurse should immediately establish continuous cardiac monitoring because, if untreated, digitalis toxicity may cause multifocal premature ventricular contractions (PVCs) that may transition to ventricular tachycardia or ventricular fibrillation. Because of digitalis' ability to have a negative chronotropic effect, bradycardia is often seen in toxicity.
The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?
- A. Humidifies nasal cannula oxygen for a client with sarcoidosis.
- B. Secures a suprapubic catheter tubing to a client’s inner thigh.
- C. Places a client with varicella-zoster in airborne and contact isolation.
- D. Suctions a tracheostomy for 10 seconds as they remove the catheter.
Correct Answer: D
Rationale: Suctioning a tracheostomy for 10 seconds (D) risks hypoxia and trauma, requiring follow-up as it should be brief (5-10 seconds max). Humidifying oxygen (A), securing catheters (B), and isolating varicella (C) are correct practices.