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. Slow: Atrial fibrillation is characterized by an irregular heart rate, but it may not necessarily be slow. The rate can vary, and it is irregularly irregular.

b. Not palpable: While atrial fibrillation can result in an irregularly irregular pulse, it is not necessarily indicative of a pulse that is not palpable.

c. Irregular: Atrial fibrillation is associated with an irregularly irregular pulse due to the chaotic and disorganized atrial activity.

d. Bounding: Bounding pulses are characterized by a forceful and strong pulse, which is not typically associated with atrial fibrillation.

A. Orthopnea B. Peripheral edema C. Frothy sputum D. Dyspnea

Correct Answer is B

Explanation

a. Orthopnea: Orthopnea is more commonly associated with left-sided heart failure, where fluid backs up into the lungs, making it difficult to breathe when lying down.

b. Peripheral edema: Right-sided heart failure can lead to systemic venous congestion, resulting in peripheral edema, often evident in the lower extremities.

c. Frothy sputum: Frothy sputum is more indicative of pulmonary edema, which is associated with left-sided heart failure.

d. Dyspnea: While dyspnea can occur with right-sided heart failure, it is more characteristic of left-sided heart failure.

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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?

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