When caring for an unconscious client with increasing intracranial pressure, the nursing intervention that is contraindicated is :
Elevating the head of the bed 20 degrees
Cleansing the eyes every 4 hours with normal saline
Lubricating the skin with baby oil
Suctioning the oropharynx routinely
The Correct Answer is D
Choice A reason : Elevating the head of the bed to 20 degrees can help reduce intracranial pressure by promoting venous drainage from the brain. It is a recommended practice unless contraindicated by other conditions³.
Choice B reason : Cleansing the eyes with normal saline every 4 hours is a standard care procedure to maintain eye hygiene and prevent infection, especially when the blink reflex may be compromised in an unconscious patient³.
Choice C reason : Lubricating the skin with baby oil is a common practice to prevent dryness and maintain skin integrity. It is not contraindicated unless the patient has specific allergies or skin conditions that require different care³.
Choice D reason : Suctioning the oropharynx routinely is contraindicated as it can stimulate the vagus nerve and potentially increase intracranial pressure. Suctioning should be performed cautiously and only when necessary³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : Conducting 15-minute checks can be part of the safety measures for a client at risk of self-harm, but it may not be sufficient for someone who is actively hearing voices commanding self-harm and refusing to engage in safety planning. These checks are less intensive and may not provide the immediate intervention needed to ensure the client's safety¹.
Choice B reason : Encouraging the client to express feelings related to suicide is an important therapeutic intervention that can provide insight into the client's emotional state and risk factors. However, if the client is actively psychotic and not engaging in safety planning, this approach alone may not be enough to ensure immediate safety¹.
Choice C reason : Placing the client on one-to-one observation is the most direct and immediate intervention to ensure safety when a client is experiencing psychotic features and is at risk of self-harm. This level of observation means that the client is never alone, and a staff member is always present to intervene if the client attempts self-harm¹.
Choice D reason : Obtaining an order for locked seclusion can be considered if other less restrictive measures are not sufficient to ensure the client's safety. However, it is generally a last resort due to the potential for negative psychological effects and should only be used when absolutely necessary and when other interventions have failed¹.
Correct Answer is B
Explanation
Choice A reason : Albuterol is a bronchodilator often used in asthma to relieve symptoms of bronchospasm. While it can help open airways, in a case of anaphylaxis, it does not address the systemic histamine release and is not the first-line treatment¹.
Choice B reason : Epinephrine is the primary treatment for anaphylaxis, which is a severe allergic reaction that can occur after a bee sting. It works rapidly to improve breathing, stimulate the heart, reverse hives, and reduce swelling of the face, lips, and throat¹³. In an emergency situation where a patient is experiencing anaphylactic symptoms such as difficulty breathing and a feeling of a lump in the throat, immediate administration of epinephrine is critical to counteract the reaction.
Choice C reason : The term "high-residual cannula" does not correspond to a recognized medical treatment or device. In the context of anaphylaxis, oxygen may be administered via a high-flow nasal cannula if the patient is experiencing respiratory distress, but this would be secondary to the administration of epinephrine.
Choice D reason : The option "Administer 5 mg prescription of the bee" is nonsensical as it does not refer to a legitimate medical treatment. In the context of bee stings, no medication is prescribed as "prescription of the bee."
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