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The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department?
- A. A 4-cm area of bright red drainage on the dressing.
- B. A weak pulse, shallow respirations, and cool pale skin.
- C. Pupils that are equal, react to light, and accommodate.
- D. Complaints of a headache that resolves with medication.
Correct Answer: B
Rationale: Signs of shock (weak pulse, shallow respirations, cool pale skin, B) suggest internal bleeding or serious injury post-fall, warranting ED transfer. Minor drainage (A) is expected, normal pupils (C) are reassuring, and a resolving headache (D) is not urgent.
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Which collaborative intervention should the nurse implement when caring for the client with West Nile virus?
- A. Complete neurovascular examinations every eight (8) hours.
- B. Maintain accurate intake and output at the end of each shift.
- C. Assess the client’s symptoms to determine if there is improvement.
- D. Administer intravenous fluids while assessing for overload.
Correct Answer: D
Rationale: IV fluids (D) support hydration in West Nile virus while monitoring for overload prevents complications. Neurovascular exams (A) are less relevant, intake/output (B) is routine, and symptom assessment (C) is nursing-driven.
The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question?
- A. A subcutaneous anticoagulant.
- B. An intravenous osmotic diuretic.
- C. An oral anticonvulsant.
- D. An oral proton pump inhibitor.
Correct Answer: A
Rationale: Subcutaneous anticoagulants (A) increase bleeding risk in head injury patients, where intracranial hemorrhage is a concern, and should be questioned. Osmotic diuretics (B) reduce ICP, anticonvulsants (C) prevent seizures, and proton pump inhibitors (D) protect against stress ulcers.
When preparing the client for an EEG, which nursing action is most appropriate?
- A. Administer a sedative 1 hour before the test.
- B. Withhold food and water after midnight on the day of the test.
- C. Assist with shampooing the client's hair.
- D. Take the client's blood pressure while lying and sitting.
Correct Answer: C
Rationale: Shampooing the client's hair ensures a clean scalp, improving electrode contact for an accurate EEG.
The 80-year-old male client on an Alzheimer’s unit is agitated and asking the nurse to get his father to come and see tenor him. Which is the nurse’s best response?
- A. Tell the client his father is dead and cannot come to see him.
- B. Give the client the phone and have him attempt to call his father.
- C. Ask the client to talk about his father with the nurse.
- D. Call the family so they can tell the client why his father cannot come to see him.
Correct Answer: C
Rationale: In Alzheimer’s, agitation and confusion require validation. Talking about his father (C) redirects and calms the client. Stating death (A) may distress, calling (B) reinforces delusion, and involving family (D) is unnecessary.
The client is to receive a 100-mL intravenous antibiotic over 30 minutes via an intravenous pump. At what rate should the nurse set the IV pump?
Correct Answer: 200 mL/hr
Rationale: To infuse 100 mL over 30 minutes, calculate the hourly rate: (100 mL / 30 min) × 60 min/hr = 200 mL/hr. The pump should be set to 200 mL/hr.