Nokea
The nursing care plan for a five-year-old with a closed head injury should contain which of the following?
- A. Encourage child to sleep and decrease stimuli in the room.
- B. Assess orientation to person, place, and time every hour.
- C. Notify the physician regarding a negative Babinski reflex.
- D. Increase fluid intake to maintain adequate urinary output.
Correct Answer: B
Rationale: early signs of increased intracranial pressure are alterations in orientation
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The nurse is caring for a client with a new tracheostomy.
- A. What is the priority nursing intervention for a client with a new tracheostomy?
- B. Suction the tracheostomy every 2 hours.
- C. Change the tracheostomy ties daily.
- D. Monitor the stoma for signs of infection.
- E. Keep the tracheostomy cuff inflated at all times.
Correct Answer: C
Rationale: Monitoring the stoma for signs of infection is the priority to detect complications early, ensuring airway safety. Suctioning is as needed, ties are changed as needed, and continuous cuff inflation risks tracheal damage.
A client is scheduled to have a parathyroidectomy. The nurse would be MOST concerned if the client was observed eating quantities of food from which of the following food groups?
- A. Milk products.
- B. Green vegetables.
- C. Seafood.
- D. Poultry products.
Correct Answer: A
Rationale: low-calcium diet is recommended preoperatively
A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?
- A. Lemonade.
- B. Prune juice.
- C. Milk.
- D. Orange juice.
Correct Answer: B
Rationale: promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon
The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results should the nurse report immediately?
- A. PTT of 90 seconds.
- B. INR of 1.0.
- C. Platelet count of 150,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range (60–80 seconds), increasing bleeding risk. Options B, C, and D are normal.
The nurse performs a routine IV tubing change on a 55-year-old woman with a central line. Fifteen minutes later, the nurse reenters the patient's room to find her cyanotic, short of breath, and complaining of pain. Her vital signs are BP 84/62, pulse 112, respirations 18.
What is the FIRST action the nurse should take?
- A. Call the physician to report the patient's symptoms.
- B. Lower the head of the bed and place the patient on her left side.
- C. Place the patient in high Fowler's position.
- D. Start oxygen at 4 L/min via nasal cannula.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) second action, first should respond to potential problem of emboli (2) correct-air will rise to right atrium, minimizes chance of air bubbles entering cerebral circulation (3) never done with shock, trapped air could travel to pulmonary circulation (4) not first action