RN: Med Surg
A nurse is caring who has viral meningitis. Which of the following actions should the nurse take?
Check the capillary refill time Why?: A vascular assessment is required every 4 hrs to monitor for any vascular compromise.
A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take?
Establish IV access Why?: You should prepare administer 0.9% sodium chloride if seizures are imminent. If the client is stable the nurse should initiate a saline lock.
A nurse is caring for a client who has retinal detachment. Which of the following findings should the nurse expect?
Flashes of bright light. Why?: In retinal detachment you will see flashes of bright light or dark spots in the visual fields. This can also be described as the "curtains going down".
A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority?
Maintain a PaCO2 of apprx. 35 mm Hg Why?: The greatest risk to a client following traumatic brain injury is the possibility of increased intercranial pressure and hypercarbia. Therefore, you want to reduce this incidence by maintaining a therapeutic level of partial pressure of CO2 of at least 35 mm Hg. [ Normal range of PaCO2: 35 TO 45 mm Hg ]
A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition (urination)?
Stroke the client's inner thigh. WHY?: As a nurse you want to promote micturition by stimulation and the technique used is stroking the inner thigh or pinching the skin above the groin. The nerves send impulses and the muscle begin to contract.
