A nurse is caring for a client.

Exhibits

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Potential Prescription: Anticipated /Nonessential /Contraindicated

Encourage the client to cough.

Keep the client's head in a midline position.

Elevate the head of the bed.

Assist the client to the bathroom.

Initiate seizure precautions.

Decrease oxygen to 1.5 L/min via nasal cannula.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}

A)   Coughing is not directly related to the client's condition as described in the scenario.
B)   Keeping the client's head in a midline position is anticipated to maintain an open airway and prevent further complications, particularly after a cerebrovascular accident.
C)   Elevating the head of the bed is anticipated as it can help improve respiratory function and reduce intracranial pressure, which is beneficial given the client's history of cerebrovascular accident and current restlessness and agitation.
D)   Assisting the client to the bathroom is contraindicated due to the client's current unresponsiveness and risk of falls; a bedpan or catheter may be more appropriate.
E)   Initiating seizure precautions is anticipated because the client's Glasgow Coma Scale score indicates a decreased level of consciousness, which could predispose them to seizures, especially with a history of cerebrovascular accident.
F)   Decreasing oxygen to 1.5 L/min via nasal cannula is contraindicated given the client's decreased oxygen saturation levels; instead, the nurse should anticipate the need to maintain or increase oxygen to ensure adequate tissue perfusion.

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Correct Answer is B

Explanation

A) Limiting time for visitors is necessary in this case. However, the time should be limited to 1 hour in 24 hours and not 2 hours.
B) Instructing visitors to remain 6 feet from the client is crucial for their safety to minimize radiation exposure. Brachytherapy involves the use of a radioactive source placed close to or inside the tumor, and while the patient is emitting radiation, safety precautions must be taken to protect others from exposure. Safety measures such as maintaining a safe distance help ensure that the radiation exposure to others is As Low As Reasonably Achievable (ALARA), a principle that aims to minimize exposure while achieving the necessary therapeutic effect.
C) Discarding the radioactive device in the client's trash can is incorrect as it poses a risk of exposure to others.
D) Keeping soiled bed linens in the client's room is incorrect as they may be contaminated with radiation and should be handled according to radiation safety protocols.

A. Slow infusion rate and contact the provider. B. Lower the head of the bed to semi-Fowler's. C. Administer prescribed corticosteroids. D. Change infusion to lactated Ringer's and maintain rate.

Correct Answer is A

Explanation

A. The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B. Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C. Administering corticosteroids is not indicated based on the client's symptoms and situation.
D. Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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