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 ["B","E"]

Explanation

A. Collect a serum sample for hemoglobin and hematocrit: Hemoglobin and hematocrit levels assess for anemia or blood loss but are not the priority for a client showing signs of a severe urinary tract infection or possible pyelonephritis.

B. Obtain clean catch urine for culture and sensitivity: A clean catch urine sample is critical to identify the specific organism causing infection and to guide targeted antibiotic therapy, improving treatment effectiveness.

C. Give diphenhydramine prep for intravenous pyelogram: Diphenhydramine may be used before contrast studies to prevent allergic reactions, but an imaging study like an IVP is not immediately necessary before addressing infection and stabilization.

D. Force oral fluids to 2,000 mL/24 hours: While hydration is important, "forcing" oral fluids to 2,000 mL may be insufficient or inappropriate if the client is experiencing nausea/vomiting or requires IV hydration to maintain hemodynamic stability and renal perfusion.

E. Initiate broad spectrum IV antibiotic as secondary infusion: Starting broad-spectrum antibiotics promptly is vital to treat the infection early, especially given systemic symptoms like fever and flank pain, preventing further complications.

A. Insert the medication as a rectal suppository. B. A second dose of medication should be given in two weeks. C. Only children with perianal itching should take the medication. D. It is safe for children of all ages to take this medication.

Correct Answer is B

Explanation

A. Insert the medication as a rectal suppository: Mebendazole is administered orally, not rectally. It is typically given in tablet or chewable form.

B. A second dose of medication should be given in two weeks: A second dose is recommended to eliminate any newly hatched worms, as mebendazole does not kill eggs, which helps prevent reinfection.

C. Only children with perianal itching should take the medication: Pinworm infections are highly contagious; household contacts, even if asymptomatic, are often treated to prevent reinfection and spread.

D. It is safe for children of all ages to take this medication: Mebendazole is not approved for use in children under 2 years of age without specific medical direction, so age-specific safety must be considered.

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Naxlex Comprehensive Predictor Exams

An adult is admitted with acute flank pain, a 102° F (38.9° C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.

Correct Answer is ["B","E"]

Explanation

The school nurse is preparing a teaching pamphlet in response to requests from parents regarding an outbreak of pinworms at the local preschool. Which information about the most commonly prescribed medication, mebendazole, should be included?

Correct Answer is B

Explanation

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Patient Data Exhibits Which laboratory tests would be helpful in determining the plan of care for this client? Select all that apply.

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

Patient Data The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

Exhibits Choose the most likely options missing from the statements by selecting from the list of options provided. The nurse teaches the client about the fetus reactions to labor by dropdown . The nurse will assess the fetus reaction by dropdown.