Nokea
The nurse managing a client's post-supratentorial craniotomy care should assure that the client is maintained in which position?
- A. Prone
- B. Supine
- C. Semi-Fowler's
- D. Dorsal recumbent
Correct Answer: C
Rationale: Following a supratentorial craniotomy, the client should be maintained in a semi-Fowler's position (head of bed elevated 30 to 45 degrees) to promote venous drainage from the brain, reduce intracranial pressure, and prevent swelling at the surgical site. The prone position could increase pressure on the surgical site and impede breathing. The supine position may increase intracranial pressure due to poor venous drainage. The dorsal recumbent position, while flat with knees flexed, does not provide the elevation needed to reduce intracranial pressure effectively.
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A hospitalized client awaiting repair of an unruptured cerebral aneurysm is frequently assessed by the nurse. Which assessment finding should the nurse identify as an early indication that the aneurysm has ruptured?
- A. Widened pulse pressure
- B. Unilateral motor weakness
- C. Unilateral slowing of pupil response
- D. A decline in the level of consciousness
Correct Answer: D
Rationale: Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure in the brain is a change in the level of consciousness. This change in consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brain than those that control consciousness, blood pressure alteration is a later sign. Slowing of pupil response and motor weakness are also late signs.
A client is admitted to the cardiac intensive care unit after coronary artery bypass graft (CABG) surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets this data and implements which intervention?
- A. Identifies that the tube is draining normally
- B. Assesses the tube to locate a possible occlusion
- C. Auscultates the lungs for appropriate bilateral expansion
- D. Assists the client with frequent coughing and deep breathing
Correct Answer: B
Rationale: After CABG surgery, chest tube drainage should not exceed 100 to 150 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after CABG surgery. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further assessment by the nurse. Options 1, 3, and 4 are incorrect interventions.
The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child's surgical incision?
- A. Rinsing the incision with sterile water after feeding
- B. Cleaning the incision only when serous exudate forms
- C. Rubbing the incision gently with a sterile cotton-tipped swab
- D. Replacing the Logan bar carefully after cleaning the incision
Correct Answer: A
Rationale: The incision should be rinsed with sterile water after every feeding. Rubbing alters the integrity of the suture line. Rather, the incision should be patted or dabbed. The purpose of the Logan bar is to maintain the integrity of the suture line. Removing the Logan bar on the first postoperative day would increase tension on the surgical incision.
An anxious client enters the emergency department seeking treatment for a laceration of the finger. The client's vital signs are pulse 106 beats per minute, blood pressure (BP) 158/88 mm Hg, and respirations 28 breaths per minute. After cleansing the injury and reassuring the client, the nurse rechecks the vital signs and notes a pulse of 82 beats per minute, BP 130/80 mm Hg, and respirations 20 breaths per minute. Which factor likely accounts for the change in vital signs?
- A. Cooling effects of the cleansing agent
- B. Client's adaptation to the air conditioning
- C. Early clinical indicators of cardiogenic shock
- D. Decline in sympathetic nervous system discharge
Correct Answer: D
Rationale: Physical or emotional stress triggers sympathetic nervous system stimulation. Increased epinephrine and norepinephrine cause tachycardia, high blood pressure, and tachypnea. Stress reduction then returns these parameters to baseline as the sympathetic discharge falls.
The nurse monitors the client taking amitriptyline for which common side effect?
- A. Diarrhea
- B. Drowsiness
- C. Hypertension
- D. Increased salivation
Correct Answer: B
Rationale: Common side effects of amitriptyline (a tricyclic antidepressant) include the central nervous system effects of drowsiness, fatigue, lethargy, and sedation. Other common side effects include dry mouth or eyes, blurred vision, hypotension, and constipation. The nurse monitors the client for these side effects.