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 client diagnosed with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. What intervention should the nurse implement for this procedure to be beneficial?
- A. Obtain baseline arterial blood gases.
- B. Obtain baseline pulse oximetry levels.
- C. Apply the mask to the face with a snug fit.
- D. Remove the mask for deep breathing exercises.
Correct Answer: C
Rationale: The CPAP face mask must be applied over the nose and mouth with a snug fit, which is necessary to maintain positive pressure in the client's airways. The nurse obtains baseline respiratory assessments and arterial blood gases to evaluate the effectiveness of therapy, but these are not done to increase the effectiveness of the procedure. A disadvantage of the CPAP face mask is that the client must remove it for coughing, eating, or drinking. This removes the benefit of positive pressure in the airway each time it is removed.
When planning care for a client diagnosed with Cushing's syndrome, the nurse should include which intervention to prevent a common complication of this disorder?
- A. Monitoring glucose levels
- B. Encouraging rigorous exercise
- C. Monitoring epinephrine levels
- D. Encouraging visits from friends
Correct Answer: A
Rationale: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol by the adrenal cortex or the administration of glucocorticoids in large doses for several weeks or longer. In the client with Cushing's syndrome, increased levels of glucocorticoids can result in hyperglycemia and signs and symptoms of diabetes mellitus. Clients experience activity intolerance related to muscle weakness and fatigue; therefore, option 2 is incorrect. Epinephrine levels are not affected. Visitors should be limited because of the client's impaired immune response.
A client arrives at the emergency department with upper gastrointestinal (GI) bleeding that began 3 hours ago. What is the priority action?
- A. Obtaining vital signs
- B. Inserting a nasogastric (NG) tube
- C. Asking the client about the precipitating events
- D. Completing an abdominal physical assessment
Correct Answer: A
Rationale: The priority action for the client with GI bleeding is to obtain vital signs to determine whether the client is in shock from blood loss and obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. A complete abdominal physical assessment must be performed but is not the priority. Insertion of an NG tube may be prescribed but is not the priority action.
A client newly diagnosed with polycystic kidney disease asks the nurse to explain again what the most serious complication of the disorder might be. The nurse will provide the client with information concerning which condition?
- A. Diabetes insipidus
- B. End-stage renal disease (ESRD)
- C. Chronic urinary tract infection (UTI)
- D. Syndrome of inappropriate antidiuretic hormone (SIADH) secretion
Correct Answer: B
Rationale: In polycystic kidney disease, cystic formation and hypertrophy of the kidneys occur. The most serious complication of polycystic kidney disease is ESRD, which is managed with dialysis or transplant. There is no reliable way to predict who will ultimately progress to ESRD. Chronic UTIs are the most common complication because of the altered anatomy of the kidney and from development of resistant strains of bacteria. Diabetes insipidus and SIADH secretion are unrelated disorders.
A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing?
- A. Peanut butter and jelly sandwich, apple, tea
- B. Chicken breast, broccoli, strawberries, milk
- C. Veal chop, boiled potatoes, Jell-O, orange juice
- D. Pasta with tomato sauce, garlic bread, ginger ale
Correct Answer: B
Rationale: The meal with the best potential to promote wound healing includes nutrient-rich food choices, including protein, such as chicken and milk, and vitamin C, such as broccoli and strawberries. The remaining options include one or more items with a low nutritional value, especially the tea, jelly, Jell-O, and ginger ale.