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 B

Explanation

a. Neck vein distention: Neck vein distention may indicate fluid overload, but it is not a direct measure of fluid losses.

b. Body weight: Monitoring body weight before and after hemodialysis provides a direct

measure of fluid losses. Hemodialysis removes excess fluid, and changes in body weight reflect fluid balance.

c. Abdominal girth: Abdominal girth may be affected by fluid accumulation but is not a direct measure of fluid losses during hemodialysis.

d. Blood pressure: While blood pressure may be influenced by fluid status, it is not a specific measure of fluid losses during hemodialysis. Body weight is a more direct indicator of fluid removal.

A. Allow the client to take her morning vitamins. B. Allow the client to keep her tongue stud in. C. Allow the client to keep her hearing aids in. D. Allow the client to consume clear liquids up to the time of surgery.

Correct Answer is C

Explanation

a. Allow the client to take her morning vitamins: This is generally acceptable unless there are specific preoperative instructions regarding medication.

b. Allow the client to keep her tongue stud in: Metallic objects, including tongue studs, are

usually removed before surgery to prevent interference with equipment and to ensure patient safety.

c. Allow the client to keep her hearing aids in: It is important for the client with a hearing

impairment to keep hearing aids in place to facilitate communication and maintain awareness of the environment.

d. Allow the client to consume clear liquids up to the time of surgery: Clear liquids are typically restricted before surgery to prevent aspiration. This action may not align with standard

preoperative fasting guidelines.

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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

Naxlex Comprehensive Predictor Exams

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