A nurse is contributing to the plan of care for a client who had a craniotomy. Which of the following interventions should the nurse include in the plan?

Apply a warm cloth over the client's eyes.

Place the client in a supine position.

Maintain seizure precautions.

Obtain a prescription for an opioid medication for pain.

Answer and Explanation

The Correct Answer is C

a. Apply a warm cloth over the client's eyes: This intervention is not typically indicated for a client who had a craniotomy. It is important to monitor for signs of increased intracranial pressure, but a warm cloth over the eyes is not a standard intervention.

b. Place the client in a supine position: The position of the client after a craniotomy will depend on the surgeon's preference. It is important to follow specific postoperative positioning

instructions, which may or may not include supine positioning.

c. Maintain seizure precautions: Seizure precautions are crucial for clients who have had a craniotomy, as they are at an increased risk of seizures postoperatively.

d. Obtain a prescription for an opioid medication for pain: Pain management is important, but opioid medications may be carefully titrated due to the potential for respiratory depression and other side effects. It is not the primary intervention in the immediate postoperative period.

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Correct Answer is C

Explanation

a. Magnesium 1.9 mg: This magnesium level is within the expected reference range (1.3-2.1 mEq/L).

b. Chloride 99 mEq/L: This chloride level is within the expected reference range (98-106 mEq/L).

c. Sodium 126 mEq/L: A sodium level of 126 mEq/L is significantly below the normal range (135-145 mEq/L), indicating hyponatremia, which can have serious consequences and requires prompt attention.

d. Potassium 3.6 mEq/L: This potassium level is within the expected reference range (3.5-5.0 mEq/L).

A. Rest in a supine position. B. Breathe in through her nose and out through pursed lips. C. Limit fluid intake throughout the day. D. Consume a low-protein diet.

Correct Answer is B

Explanation

a. Rest in a supine position: Resting in a supine position may compromise lung expansion, and an upright position is often recommended for clients with emphysema to improve ventilation.

b. Breathe in through her nose and out through pursed lips: This technique helps maintain

positive airway pressure, preventing premature airway collapse, and can improve gas exchange in clients with emphysema.

c. Limit fluid intake throughout the day: Adequate hydration is important for maintaining

respiratory secretions in a liquefied state and is generally encouraged for clients with respiratory conditions.

d. Consume a low-protein diet: A low-protein diet is not specifically indicated for improving gas exchange in clients with emphysema. Nutrition recommendations may focus on a well-balanced diet to support overall health.

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A nurse is contributing to the plan of care for a client who had a craniotomy. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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