occupational therapy. accident analysis. ergonomics. body mechanics.
An ICU nurse monitors a client recovering from a head injury. The client’s intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client’s endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
increase the rate of the sedative IV drip. chart the findings and continue to monitor the client. reposition the client. contact the physician.
A labor and delivery nurse is caring for a newborn baby whose mother was a regular cocaine user during the entire pregnancy (prenatal cocaine exposure). The nurse expects the newborn to
present with irritability, trouble sleeping, and a shrill cry. present with lethargy, poor muscle tone, and inability to cry. require pharmaceutical support for cocaine withdrawal. benefit from a regular breastfeeding schedule.
A 46-year-old male has been placed under therapeutic hypothermic care after a myocardial infarction (MI). The nurse correctly explains to the family
“Therapeutic hypothermia increases the production of neurotransmitters in the brain.” “Therapeutic hypothermia will repair damaged cardiac tissue.” “Therapeutic hypothermia will help protect the brain from injury by slowing metabolism.” “Therapeutic hypothermia will slow the heart rate to reduce likelihood of another MI.”
A nurse is asked to prepare a client for placement of a central venous catheter that will be inserted into the right jugular vein. The nurse asks the client to
lie in a supine position with the head turned to the right. sit in a high-Fowler’s position with the head turned to the left. lie in the Trendelenburg position with the head turned to the left. lie in a supine position with the head positioned straight.
A med-surg nurse is floating to the post-op floor for a few days. The float nurse sees one of the regular post-op nurses taking medication out of the med cart and ingesting several pills. The float nurse should immediately
inform the state board of nursing. inform the nursing supervisor who works on the post-op floor. report the nurse to human resources. confront the post-op nurse about stealing and abusing medications.
A school nurse is suspicious that a child is being physically abused at home. The nurse’s responsibility is to
ask the child if the suspicions of abuse are accurate and true. speak with the caregivers to share the abuse suspicions. accurately and fully document this in the child’s chart. report the situation to the local authorities.
The nurse is caring for a client who received tissue plasminogen activator 2 hours ago. The nurse would be most concerned by which of the following in the client?
blood pressure of 134/91 bright red blood streaks in the stool temperature of 40.1°C ankle edema
A 32-year-old male client has just undergone a liver biopsy and is released to the post-op floor for observation. The nurse should have the client lie in what position?
semi-Fowler’s on his right side supine on his left side
The nursing assistant is taking vitals for a client on mechanical ventilation. Which of the following findings should the nursing assistant report to the nurse immediately?
respiratory rate 26 breaths/minute heart rate 82 beats/minute blood pressure 152/86 mmHg temperature 102.1°F