What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?

Vocalization, strength, and pupillary response and accommodation

Eye opening. verbal response, and motor response

Pupillary reaction, eye opening, and motor response

Motor response. sensory response, and level of consciousness

Answer and Explanation

The Correct Answer is B

A. Vocalization, strength, and pupillary response and accommodation are not components of GCS. Strength testing is part of a motor exam, and pupillary response is part of a cranial nerve assessment.

B. Eye opening, verbal response, and motor response are the three components of the Glasgow Coma Scale (GCS), which assesses a client’s neurological status and level of consciousness.

C. Pupillary reaction, eye opening, and motor response is incorrect because pupillary reaction is not a component of the GCS.

D. Motor response, sensory response, and level of consciousness is incorrect because sensory response is not a part of the GCS.

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Free Nursing Study Resources

Correct Answer is ["31"]

Explanation

Flow rate=(Total volume×Drop factor)÷ Time in minutes

= (250×15)÷120

= 31.25

A. Removal of the educating patient to carry an Epipen B. Assess and document for previous allergies and drug reactions prior to medication administration C. Administer diphenhydramine and solumedrol IV and solumedrol IV at the first sign of allergic symptoms D. Application of red allergy bracelet patient's upper extremity

Correct Answer is B

Explanation

A. Removal of the educating patient to carry an Epipen
While educating the patient about carrying an Epipen is essential in managing anaphylaxis, it is not the primary action in preventing anaphylactic shock before exposure to an allergen.

B. Assess and document for previous allergies and drug reactions prior to medication administration
Identifying and documenting allergies before administering medications or treatments helps prevent exposure to known allergens, reducing the risk of anaphylaxis.

C. Administer diphenhydramine and solumedrol IV at the first sign of allergic symptoms
These medications help in managing allergic reactions but do not prevent anaphylactic shock. Preventive measures focus on avoiding allergen exposure rather than treating symptoms after they occur.

D. Application of a red allergy bracelet on the patient’s upper extremity
This helps alert healthcare providers about allergies, but it does not prevent anaphylactic shock. It is a precautionary step rather than a primary prevention strategy.

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What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?

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Naxlex Comprehensive Predictor Exams

A patient is ordered 1 unit of packed red blood cells (250mL) to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

Correct Answer is ["31"]

Explanation

What action priority in preventing anaphylactic shock?

Correct Answer is B

Explanation

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