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A nurse is reviewing the prescriptions for a client who has a new diagnosis of bacterial meningitis. Which of the following prescriptions should the nurse clarify with the provider?

A.

Place the client on droplet precautions.

B.

Perform a cranial nerve assessment on the client every 2 hr.

C.

Assist the client out of bed three times per day.

D.

Assess the client's weight daily.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Placing the client on droplet precautions is appropriate for bacterial meningitis, as it is spread through respiratory droplets. This measure helps prevent the spread of infection to others.
Choice B rationale:
The nurse should clarify the prescription to perform a cranial nerve assessment every 2 hours. While cranial nerve assessment is crucial in monitoring neurological status, performing it every 2 hours is excessive and not supported by evidence-based practice. Frequent assessments can be uncomfortable for the client and may not provide additional meaningful information within such a short interval.
Choice C rationale:
Assisting the client out of bed three times per day is essential for promoting mobility and preventing complications such as pressure ulcers and muscle weakness. This prescription is appropriate and does not require clarification.
Choice D rationale: 
Assessing the client's weight daily is essential in monitoring fluid balance and nutritional status. There is no need to clarify this prescription, as it is a standard practice in caring for clients with bacterial meningitis.


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Related Questions

Correct Answer is B

Explanation

Let's break down the calculation:

Given:

  • Patient weight: 154 lbs
  • Enoxaparin dosage: 0.75 mg/kg
  • Available enoxaparin: 60 mg/0.6 mL

Step 1: Convert pounds to kilograms:

  • 1 lb is approximately 0.4536 kg
  • So, 154 lbs = 154 * 0.4536 kg/lb = 69.85 kg (approximately 70 kg)

Step 2: Calculate the total dose of enoxaparin:

  • Desired dose = 0.75 mg/kg * 70 kg = 52.5 mg

Step 3: Determine the volume to administer:

  • We have enoxaparin 60 mg/0.6 mL
  • To find the volume for 52.5 mg:
    • (52.5 mg / 60 mg) * 0.6 mL = 0.525 mL
    • Rounded to the nearest tenth, this is 0.5mL.

Therefore, the nurse should administer 0.5mL of enoxaparin

Correct Answer is C

Explanation

Choice A rationale:
Assessing the need for oral suction every 4 hours is essential in maintaining airway patency and preventing complications associated with excessive secretions. This is an appropriate action and does not require clarification.
Choice B rationale:
Checking the ventilator settings every 12 hours is necessary to ensure that the mechanical ventilation is providing adequate support for the client's respiratory needs. This prescription is appropriate and does not need clarification.
Choice C rationale:
Keeping the head of the client's bed elevated at 30° is important in preventing aspiration and ventilator-associated pneumonia. This position helps promote optimal lung expansion and improves oxygenation in ventilated clients.
Choice D rationale:
Performing oral hygiene using an alcohol-based oral rinse is not recommended for clients receiving mechanical ventilation. Alcohol-based products can be harmful if aspirated and may disrupt the normal oral flora, leading to complications. The nurse should use a non-alcohol-based oral rinse or foam swabs instead.

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