Exam 7 - Neuro
The client is to receive aa 100-mL intravenous antibiotic over 30 minutes via an intravenous pump. At what rate should the nurse set the IV pump? __________
200mL per 1 hour
The rehabilitation nurse caring for the client with a lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement? a. keep oxygen via nasal cannula on at all times b. administer low-dose subcutaneous anticoagulants c. perform active lower extremity ROM exercises d. refer to a speech therapist for ventilator-assisted speech
B. administer low-dose subcutaneous anticoagulants Rationale: DVT is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the lumbar SCI. Low-dose anticoagulant therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVTs.
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication? a. "I will brush my teeth after every meal." b. "I will check my Dilantin level daily." c. "My urine will turn orange while on Dilantin." d. "I won't have any seizures while on this medication."
a. "I will brush my teeth after every meal."
The client with end-stage ALS requires a gastronomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding? a. a residual of 125mL b. the abdomen is soft c. three episodes of diarrhea d. the potassium level is 3.4 mEq/L
a. a residual of 125mL
The nurse in the neurointensive care unit is caring for a client with a new cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. a. monitor the pulse oximetry reading b. provide pureed foods six (6) times a day c. encourage coughing and deep breathing d. assess for autonomic dysreflexia e. administer intravenous corticosteroids
a. monitor the pulse oximetry reading c. encourage coughing and deep breathing e. administer intravenous corticosteroids
The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take? a. help the UAP insert the oral airway in the mouth b. tell the UAP to stop trying to insert anything in the mouth c. take no action because the UAP is handling the situation d. notify the charge nurse of the situation immediately
b. tell the UAP to stop trying to insert anything in the mouth
Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? a. teach credes maneuver to the client needing to void b. administer the tube feeding to the client who is quadriplegic c. assist with bowel training by placing the client on the bedside commode d. observe the client demonstrating self-catheterization technique
c. assist with bowel training by placing the client on the bedside commode
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevated the HOB 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2 F, P 98, R 24, and BP 84/40. Which action should the nurse implement? a. notify the health-care provider as soon as possible b. calm the client down by talking therapeutically c. increase the IV rate by 50mL/hr d. lower the head of the bed immediately.
d. lower the head of the bed immediately.
