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 ["A","C","D"]

Explanation

Choice A rationale
Introducing oneself after entering the patient’s room is a key aspect of effective communication with a blind patient. This helps the patient identify who is in the room with them.
Choice B rationale
Using a firm, loud voice when addressing the patient is not necessarily effective. While it’s important to speak clearly, raising one’s voice can come off as patronizing or disrespectful. It’s better to speak in a normal tone and adjust as needed based on the patient’s feedback.
Choice C rationale

Lightly touching the patient’s arm can be an effective way to gain their attention, especially if they may not have heard you enter the room. However, it’s important to ask for consent before touching the patient.
Choice D rationale
Providing instructions in clear, simple terms can be very helpful for a blind patient. This can help them understand what is happening and what they need to do.

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.

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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, during a shift report, learns that a patient under their care is blind. What actions by the nurse would demonstrate effective communication?

Correct Answer is ["A","C","D"]

Explanation

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

A patient with hypotension has an order for 1000 mL of 0.9% Normal Saline over 3 hours. The tubing drop factor is 10 gtt/mL. How many gtt/min should be given? (This is a med math nd does not require options)

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