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 A
Explanation
Choice A reason:
Frequent urination is a common symptom of urinary tract infections. It helps to flush out bacteria from the urinary tract.
Choice B reason:
Wiping from back to front can introduce bacteria from the anal area to the urethra, increasing the risk of urinary tract infections. The correct technique is to wipe from front to back
Choice C reason:
Nylon underwear can trap moisture, creating an environment conducive to bacterial growth. Cotton underwear is recommended for better air circulation.
Choice D reason:
Testing urine for ketones is not directly related to preventing urinary tract infections. Ketone testing is more relevant for individuals with diabetes to monitor for ketoacidosis.
Correct Answer is C
Explanation
Choice A reason:
Improved feedings can be a positive sign, but it may not directly indicate the therapeutic effect of phenobarbital.
Choice B reason:
Restored surfactant is not directly related to the action of phenobarbital, which is used to manage symptoms of neonatal abstinence syndrome.
Choice C reason:
Phenobarbital is a medication that can help alleviate CNS irritability in infants with neonatal abstinence syndrome. Therefore, a decrease in CNS irritability indicates a therapeutic effect of the medication.
Choice D reason:
Decreased excoriation is not a primary effect of phenobarbital. This medication primarily addresses CNS symptoms associated with neonatal abstinence syndrome.
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