A client sustained a head injury when hit by lead pipe two hours ago and is admitted for observation after the computerized tomography (CT) scan indicates that no spinal cord injury and no skull fractures are present. When the client begins projectile vomiting, the nurse quickly turns the client's head to the side and administers ondansetron 4 mg IV as prescribed. Reassessment indicates that the client's Glasgow coma score is 13 and the left pupil is dilated without reaction to light. Which intervention(s) should the nurse implement? Select all that apply.

Insert a second large bore IV catheter.

Schedule a repeat CT scan.

Apply artificial tear drops to left eye.

Place in lateral Trendelenburg position.

Repeat Glasgow coma assessment.

Answer and Explanation

Correct Answer : B,C,E

A. Insert a second large bore IV catheter: This may be necessary in a trauma setting if volume resuscitation is needed, but there is no indication of hemodynamic instability or bleeding in this scenario. It is not the most immediate or essential response to new neurologic findings.

B. Schedule a repeat CT scan: A dilated, non-reactive pupil and change in neurologic status may indicate increased intracranial pressure or new bleeding. A repeat CT scan is critical to evaluate for worsening brain injury or cerebral herniation.

C. Apply artificial tear drops to left eye: A non-reactive pupil suggests cranial nerve involvement, possibly impairing the eye's ability to blink. To protect the cornea from drying and ulceration, artificial tears or eye protection is appropriate.

D. Place in lateral Trendelenburg position: Trendelenburg position is contraindicated in clients with suspected increased intracranial pressure, as it may worsen cerebral edema. The head should be elevated, not lowered.

E. Repeat Glasgow coma assessment: Frequent reassessment of neurologic status using the Glasgow Coma Scale helps detect early signs of deterioration and guides the urgency of interventions such as imaging or surgical evaluation.

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

A. Cup of raspberries: Raspberries are high in dietary fiber and water content, making them an excellent choice to promote soft stools and reduce straining during bowel movements.

B. Bowl of oatmeal: Oatmeal is rich in soluble fiber, which helps bulk up and soften stools, aiding in the prevention of hemorrhoid irritation and constipation.

C. Scrambled eggs: Eggs are low in fiber and do not contribute to stool softening or bowel regulation, so they are not beneficial for a high-fiber diet.

D. Raisin bran muffins: These are typically made with whole grains and dried fruit, both good sources of dietary fiber that help improve bowel regularity.

E. Bacon slices: Bacon contains no fiber and is high in fat and sodium, which may worsen constipation and hemorrhoid symptoms.

A. Transfuse Type A negative blood until Type negative is available. B. Recheck the client's hemoglobin, blood type, and Rh factor. C. Administer normal saline solution until Type AB negative is available. D. Obtain additional consent for administration of Type A negative blood.

Correct Answer is A

Explanation

A. Transfuse Type A negative blood until Type AB negative is available: In an emergency, when AB negative blood is unavailable, Type A Rh-negative blood is an acceptable alternative for an AB negative recipient. It shares compatible A antigens and lacks the Rh factor, minimizing transfusion reaction risk.

B. Recheck the client's hemoglobin, blood type, and Rh factor: This information has already been determined, and delaying transfusion in a critical situation could worsen hypoxia and risk death.

C. Administer normal saline solution until Type AB negative is available: Saline can temporarily support circulation, but it does not address the critical oxygen-carrying deficiency from severe anemia, which requires immediate blood transfusion.

D. Obtain additional consent for administration of Type A negative blood: In life-threatening emergencies, blood transfusions may proceed under implied consent, particularly when delay would place the client at risk.

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Naxlex Comprehensive Predictor Exams

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is A

Explanation

Exhibits Click to indicate if the listed manifestion of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?

The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to a healthcare provider for evaluation of thyroid functioning?

The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.