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Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg?
- A. Give the client a warming blanket.
- B. Administer low-dose barbiturates.
- C. Encourage the client to hyperventilate.
- D. Restrict fluids.
Correct Answer: B
Rationale: Low-dose barbiturates can reduce cerebral metabolism and ICP, making them appropriate in some cases under medical supervision. Warming blankets increase metabolic demand, hyperventilation is no longer routinely recommended due to risks of cerebral vasoconstriction, and fluid restriction is not standard for ICP management unless specifically indicated.
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A client is to have a transfusion of packed red blood cells from a designated donor. The client asks if any diseases can be transmitted by this donor. The nurse should inform the client that which of the following diseases can be transmitted by a designated donor? Select all that apply.
- A. Epstein-Barr virus.
- B. Human immunodeficiency virus (HIV).
- C. Cytomegalovirus (CMV).
- D. Hepatitis A.
- E. Malaria.
Correct Answer: B,C,E
Rationale: Blood transfusions, even from designated donors, carry a risk of transmitting certain diseases. HIV, CMV, and malaria are known to be transmissible through blood transfusions if the donor is infected, as these pathogens can persist in blood. Epstein-Barr virus is less commonly associated with transfusion transmission, and hepatitis A is primarily transmitted via the fecal-oral route, not blood. The nurse should inform the client of the risks of HIV, CMV, and malaria.
Which of the following positions would be appropriate for a client with severe ascites?
- A. Fowler's.
- B. Side-lying.
- C. Reverse Trendelenburg.
- D. Sims.
Correct Answer: A
Rationale: Fowler's position (A) elevates the head, reducing diaphragm pressure from ascites and improving breathing. Side-lying (B), Reverse Trendelenburg (C), and Sims (D) are less effective for respiratory relief.
The American Heart Association (AHA) guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for:
- A. Early defibrillation in cases of atrial fibrillation.
- B. Cardiovascular placement.
- C. Early defibrillation in cases of ventricular fibrillation.
- D. None of the above
Correct Answer: C
Rationale: AEDs are used for early defibrillation in ventricular fibrillation or pulseless ventricular tachycardia, as these are shockable rhythms that can be corrected to restore cardiac function.
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)?
- A. Double vision.
- B. Sudden bursts of energy.
- C. Weakness in the extremities.
- D. Muscle tremors.
Correct Answer: B
Rationale: Sudden bursts of energy are not typical in MS, which often causes fatigue. Double vision, weakness, and tremors are common due to demyelination affecting vision, motor, and coordination.
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to:
- A. Observe careful hand-washing procedures.
- B. Clean the incisional area with an antiseptic.
- C. Use prepackaged sterile dressings to cover the incision.
- D. Place soiled dressings in a waterproof bag before disposing of them.
Correct Answer: A
Rationale: Hand-washing is the most effective measure to prevent wound infection, as it reduces the risk of introducing pathogens during dressing changes.