The nurse is providing care for a comatose patient and regularly assessing for potential complications. What complications should the nurse be looking for?

Venous thromboembolism

Hemorrhage

Contractures

Pressure ulcers

Pneumonia

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale

Venous thromboembolism (VTE) is a serious complication that can occur in comatose patients. Immobility is a major risk factor for VTE, and comatose patients are often immobile. Therefore, nurses should be vigilant for signs of VTE, such as swelling, pain, or redness in the extremities.
Choice B rationale
Hemorrhage is not typically a direct complication of coma. However, the underlying cause of the coma, such as a traumatic brain injury, could potentially lead to hemorrhage.
Choice C rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can occur in comatose patients due to prolonged immobility. Regular movement and physiotherapy can help prevent this complication.
Choice D rationale
Pressure ulcers, also known as bedsores, are a common complication in comatose patients. They occur when there is prolonged pressure on the skin, usually over bony areas. Regular turning and good skin care can help prevent pressure ulcers.
Choice E rationale
Pneumonia is a common complication in comatose patients, often resulting from aspiration (inhaling food, stomach acid, or saliva into the lungs)2. Nurses should be vigilant for signs of pneumonia, such as fever, cough, and difficulty breathing.

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Correct Answer is ["2 "]

Explanation

Step 1 is: To calculate the rate at which the IV pump should be set to deliver the PRBCs, we need to divide the total volume of PRBCs by the total time for administration.

Step 2 is: Convert the time for administration from hours to minutes because the rate is typically set in mL/min. So, 3 hours is equivalent to 180 minutes.

Step 3 is: Now, divide the total volume of PRBCs (350 mL) by the total time for administration (180 min). So, the calculation is 350 mL ÷ 180 min.

Step 4 is: The final calculated answer is approximately 1.94 mL/min. However, IV pumps typically only allow whole numbers, so we would round this to 2 mL/min.

A. Follow up by having the client perform the Rinne test B. Reposition the client supine to ensure safety. C. Document successful completion of the assessment. D. Facilitate a referral to a neurologist.

Correct Answer is C

Explanation

Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.

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The nurse is providing care for a comatose patient and regularly assessing for potential complications. What complications should the nurse be looking for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering a 350 mL unit of PRBCs over 3 hours to a client diagnosed with anemia. The nurse should set the IV pump to deliver how many mL/hr?

Correct Answer is ["2 "]

Explanation

During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?

Correct Answer is C

Explanation

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