A nurse is reviewing a patient’s medical record.
After reviewing the medical data, which of the following actions should the nurse plan to take?
Initiate seizure precautions.
Assist the patient to the bathroom.
Keep the patient’s head in a mid position.
Decrease oxygen to 1.5 L/min via nasal cannula.
The Correct Answer is A
Choice A rationale
Without specific patient data, it’s challenging to provide a detailed rationale.
However, initiating seizure precautions could be necessary if the patient’s medical record indicates a history of seizures or a condition that increases the risk of seizures.
Choice B rationale
Assisting the patient to the bathroom is a routine nursing intervention and would not typically be determined based on a review of the patient’s medical record.
Choice C rationale
Keeping the patient’s head in a mid position would depend on the patient’s condition and would not typically be determined based on a review of the patient’s medical record.
Choice D rationale
Decreasing oxygen to 1.5 L/min via nasal cannula would depend on the patient’s oxygen saturation levels and overall respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Elevating the head of the bed 45 degrees before starting the CPM device is not necessary. The position of the bed does not affect the operation of the CPM device.
Choice B rationale
Instructing the patient to increase the degree of flexion as tolerated is not the nurse’s responsibility. The degree of flexion is usually set by the healthcare provider or physical therapist.
Choice C rationale
Ensuring the frame joint is in a flexed position before placing the leg onto the device is not necessary. The CPM device should be set up according to the manufacturer’s instructions and the healthcare provider’s orders.
Choice D rationale
Ensuring the knee joint is positioned over the CPM device frame joint is crucial. Proper alignment of the patient’s knee joint with the CPM device’s joint ensures effective and safe operation of the device.
Correct Answer is D
Explanation
Choice D.
Choice A rationale
Diminished reflexes are a common finding in older adults due to the natural aging process of the nervous system and do not necessarily indicate a bladder infection.
Choice B rationale
A WBC count of 900/mm^3 is significantly lower than the normal range of 5000 to 16,000/mm^33. While this could indicate an issue with the immune system, it does not specifically point to a bladder infection.
Choice C rationale
A temperature of 33.9°C is lower than the average body temperature and does not suggest a bladder infection. Fever is a common symptom of infection, but hypothermia is not.
Choice D rationale
Altered mental status in an older adult client can be a sign of a urinary tract infection (UTI), including a bladder infection. UTIs in older adults can present with non-specific symptoms such as changes in mental status, making them harder to diagnose.
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