The nurse is assessing a client for Brudzinskis sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? SELECT ALL THAT APPLY

Bend the client's head toward their chest

Ask the client to extend both arms above their head

Place the client in supine position

The nurse will place a hand behind the client's head

Assist the client to bend their knee 90 degrees

Answer and Explanation

Correct Answer : A,C,D

A. Bend the client’s head toward their chest is correct because Brudzinski’s sign is tested by flexing the client’s neck and observing for an involuntary flexion of the hips and knees, which suggests meningeal irritation.

B. Ask the client to extend both arms above their head is incorrect; this is not part of the test for Brudzinski’s sign.

C. Place the client in a supine position is correct because the test must be done with the client lying flat on their back.

D. The nurse will place a hand behind the client’s head is correct because the nurse gently lifts the client’s head to assess for involuntary hip and knee flexion.

E. Assist the client to bend their knee 90 degrees is incorrect; knee bending is not required for Brudzinski’s sign but is part of Kernig’s sign testing.

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Correct Answer is ["70"]

Explanation

Formula: Dose = Weight (kg) × 80 units/kg
5600 units ÷ 80 units/kg = 70 kg

A. The correct rate is 6 mL/hr to deliver 200 units/hr with a concentration of 200 units of heparin m B. After contacting the prescriber about the event Nurse A should an anticipate an order for IV Vitamin K C. The nurses will complete an event report due to the medication error D. Nurse A will document about the event report in the patients electronic medical record. E. The patient has received a dose of heparin over the prescribed amount F. The patient has received 3200 units of heparin from 1700-1900.

Correct Answer is ["C","E","F"]

Explanation

A. The correct rate is 6 mL/hr

The correct calculation should be verified.

B. After contacting the prescriber, Nurse A should anticipate an order for IV Vitamin K

Protamine sulfate, not vitamin K, is the antidote for heparin.

C. The nurses will complete an event report due to the medication error

A medication error must be reported.

D. Nurse A will document about the event report in the patient’s EMR

Incident reports are internal documents and should not be documented in the EMR.

E. The patient has received a dose of heparin over the prescribed amount

Due to the increased concentration, the patient received more heparin than intended.

F. The patient has received 3200 units of heparin from 1700-1900.

This calculation confirms overdosing.

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The nurse is assessing a client for Brudzinskis sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? SELECT ALL THAT APPLY

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A heparin IV bolus is ordered: 80 units per kilogram. The unit's pharmacist prepares & labels a dose of heparin that is 5600 units. What is the patient's weight in kilograms? _______________

Correct Answer is ["70"]

Explanation

Correct Answer is ["C","E","F"]

Explanation

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