Nokea
When planning the care for a client after a posterior fossa (infratentorial) craniotomy, which action is contraindicated?
- A. Keeping the client flat on one side
- B. Elevating the head of the bed 30°
- C. Log-rolling or turning as a unit
- D. Keeping the neck in a neutral position
Correct Answer: B
Rationale: Elevating the head of the bed can increase intracranial pressure in posterior fossa craniotomy clients due to disruption of cerebrospinal fluid flow, making it contraindicated.
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The nurse is preparing to administer an injection to a 6-month-old when she notices a white dot in the infant's right pupil. The nurse should:
- A. Report the finding to the physician immediately
- B. Record the finding and give the infant's injection
- C. Recognize that the finding is a variation of normal
- D. Check both eyes for the presence of the red reflex
Correct Answer: A
Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or cataracts, requiring immediate reporting to the physician for further evaluation.
A client with Alzheimer's disease has been prescribed donepezil (Aricept). Which information should the nurse include in the teaching plan for a client on Aricept?
- A. Take the medication with meals.'
- B. The medicine can cause dizziness, so rise slowly.'
- C. If a dose is skipped, take two the next time.'
- D. The pill can cause an increase in heart rate.'
Correct Answer: B
Rationale: Donepezil can cause dizziness due to its cholinergic effects, so clients should rise slowly to prevent falls. It's taken at bedtime, not with meals, and doses shouldn't be doubled.
The nurse is aware that a common mode of transmission of clostridium difficile is:
- A. Use of unsterile surgical equipment
- B. Contamination with sputum
- C. Through the urinary catheter
- D. Contamination with stool
Correct Answer: D
Rationale: C. difficile is transmitted via fecal-oral route through contaminated stool.
The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?
- A. Slow the transfusion
- B. Document the finding as the only action
- C. Stop the blood transfusion and turn on the normal saline
- D. Assess the client's pupils
Correct Answer: A
Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion reduces further overload while maintaining access. Stopping it entirely or documenting only delays intervention.
The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?
- A. Notify the police department as a robbery
- B. Report this behavior to the charge nurse
- C. Monitor the situation and note whether any items are missing
- D. Ignore the situation until items are reported missing
Correct Answer: B
Rationale: Reporting to the charge nurse ensures proper investigation.