The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.
The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Keep the bed in the lowest position and initiate seizure and fall precautions.

Place an indwelling urinary catheter and measure strict intake and output.

Maintain elevated positioning of the dependent joints on affected side.

Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Answer and Explanation

The Correct Answer is D

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

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Correct Answer is A

Explanation

Choice A reason: This is correct because a firm mattress reduces the risk of suffocation and rebreathing of carbon dioxide, which are associated with SIDS.

Choice B reason: This is incorrect because propping the infant with a pillow can cause the infant to slide down and suffocate or obstruct the airway.

Choice C reason: This is incorrect because swaddling the infant in a blanket can cause overheating, which is a risk factor for SIDS.

Choice D reason: This is incorrect because placing the infant in a prone position can increase the risk of SIDS by impairing gas exchange and thermoregulation.

A. Yellow-tinged sputum B. Nausea and headache C. Watery diarrhea D. Increased fatigue

Correct Answer is C

Explanation

Choice A: Yellow-tinged sputum is not a serious adverse effect of linezolid. It may indicate an infection or inflammation in the respiratory tract, but it does not require immediate attention from the health care provider.

Choice B: Nausea and headache are common side effects of linezolid. They are usually mild and self-limiting, and they can be managed with supportive measures such as hydration, rest, and analgesics.

Choice C: Watery diarrhea is a sign of pseudomembranous colitis, a potentially life-threatening complication of linezolid. It is caused by an overgrowth of Clostridium difficile bacteria in the colon, which produce toxins that damage the intestinal mucosa. It can lead to dehydration, electrolyte imbalance, sepsis, and perforation. The nurse should report this finding to the health care provider immediately and stop the linezolid infusion.

Choice D: Increased fatigue is not a specific or serious adverse effect of linezolid. It may be related to the underlying infection, anemia, or other factors. It does not require urgent intervention from the health care provider.

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The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Correct Answer is A

Explanation

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

Correct Answer is C

Explanation

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The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.
The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?