A nurse is contributing to the plan of care for a newly admitted adolescent.
A nurse is contributing to the plan of care for a newly admitted adolescent. Which of the following interventions should the nurse include?
Suction the client's airway every 2 hr.
Maintain the client's head of the bed at 30°.
Keep the client's room well lit.
Check the client's temperature every 8 hr.
The Correct Answer is B
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Muehrcke lines on the nails are associated with certain medical conditions but are not indicative of acute glomerulonephritis.
Choice B reason:
Correct. Hypertension is a common manifestation of acute glomerulonephritis due to the impaired filtration function of the kidneys.
Choice C reason:
Dehydration is not a typical manifestation of acute glomerulonephritis. Instead, fluid retention and edema are more common.
Choice D reason:
Hypokalemia (low potassium levels) is not a typical finding in acute glomerulonephritis. Instead, hyperkalemia (high potassium levels) may occur.
Correct Answer is C
Explanation
Choice A reason:
Connecting a bulb attachment to the syringe is not a standard method for administering a tube feeding and can potentially lead to complications.
Choice B reason:
Heating the formula to body temperature is not typically necessary and can be potentially dangerous if it leads to overheating.
Choice C reason:
Positioning the child with the head of the bed elevated at 15° helps to prevent aspiration during tube feeding.
Choice D reason:
Instilling the feeding based on pH alone is not a sufficient criterion for administration. Other factors, such as radiographic confirmation of tube placement, should also be considered.
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