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 A

Explanation

a. Increasing dyspnea: Atelectasis is the collapse of alveoli, leading to decreased lung volume and impaired gas exchange. Dyspnea (difficulty breathing) is a common symptom as the lung's ability to oxygenate the blood is compromised.

b. Dry cough: A dry cough may be present, but it is not specific to atelectasis. It can occur for various reasons postoperatively.

c. Facial flushing: Facial flushing is not a typical finding in atelectasis. It is more commonly associated with conditions such as fever or allergic reactions.

d. Decreasing respiratory rate: Atelectasis can lead to increased respiratory rate as the body tries to compensate for decreased lung function. A decreasing respiratory rate would be less likely in the presence of atelectasis.

A. Prothrombin time (PT) B. Platelet count C. White blood cell count (WBC) D. Activated partial thromboplastin time (aPTT)

Correct Answer is A

Explanation

a. Prothrombin time (PT): Warfarin affects the extrinsic pathway of the coagulation cascade, and PT is the primary diagnostic test used to monitor the therapeutic effect of warfarin. It measures

the time it takes for blood to clot.

b. Platelet count: Platelet count assesses the number of platelets in the blood and is not specifically used to monitor the effect of warfarin.

c. White blood cell count (WBC): WBC count assesses the number of white blood cells and is not specifically used to monitor the effect of warfarin.

d. Activated partial thromboplastin time (aPTT): While aPTT is a valuable test for monitoring the therapeutic effect of heparin, it is not the primary test for warfarin. Warfarin primarily affects the extrinsic pathway, and PT is more appropriate for monitoring its effects.

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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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