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:
Administering digoxin should be based on the infant's specific heart rate and the healthcare provider's prescription, rather than a specific pulse value.
Choice B reason:
Allowing for frequent rest periods is important for an infant with heart failure, as it helps conserve energy and reduce cardiac workload.
Choice C reason:
Feeding duration should be based on the infant's tolerance and ability to feed effectively, rather than a specific time frame.
Choice D reason:
Maintaining the infant in a supine position can help with respiratory function but should be balanced with appropriate positioning to prevent aspiration and promote comfort. It is not the sole action to include in the plan of care.
Correct Answer is A
Explanation
Choice A reason:
Using four words in a sentence is an appropriate developmental milestone for a 3-year-old child. By this age, children typically have a vocabulary that allows them to form short sentences and express themselves.
Choice B reason:
Tying shoelaces is a fine motor skill that is typically developed later, around 5-6 years of age.
Choice C reason:
Skipping on alternate feet is a gross motor skill that is typically developed around 4-5 years of age.
Choice D reason:
Naming the days of the week is a cognitive skill that is typically developed later, around 5-6 years of age. It involves not only memory but also an understanding of the concept of days and their order.
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