Nursing Elites

1. Following a craniotomy, why did the nurse position the client in low Fowler's position?

• A. To promote comfort.
• B. To promote drainage from the operation site.
• C. To promote thoracic expansion.
• D. To prevent circulatory overload.

Correct answer: B

Rationale: Positioning the client in low Fowler's position after a craniotomy is essential to promote drainage from the operation site. This position helps prevent fluid accumulation, facilitates the removal of excess fluid or blood, and aids in the healing process. Choice A is incorrect because comfort, while important, is not the primary reason for this specific positioning. Choice C is incorrect as thoracic expansion is not the main concern following a craniotomy. Choice D is incorrect as circulatory overload is not typically addressed by positioning in low Fowler's position post-craniotomy.

2. What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?

• A. Maintain the client in a lateral position using protective wrist and vest restraints.
• B. Position the client prone with a small pillow below the diaphragm.
• C. Raise the head and knee gatch when lying in a supine position.
• D. Transfer the client to a wheelchair close to the nursing station for observation.

Correct answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients. Choice A is incorrect because using restraints can lead to further complications and does not address pressure relief. Choice C is incorrect as raising the head and knee gatch in a supine position does not directly alleviate pressure over the sacrum. Choice D is incorrect as transferring to a wheelchair does not address pressure relief or optimal positioning to prevent sacral ulcers.

3. During the assessment, a client receiving a continuous infusion of heparin for deep vein thrombosis (DVT) is found to have a nosebleed. Which finding requires immediate action?

• A. The client's activated partial thromboplastin time (aPTT) is 70 seconds.
• B. The client has developed a nosebleed.
• C. The client's blood pressure is 150/90 mm Hg.
• D. The client reports feeling lightheaded.

Correct answer: B

Rationale: A nosebleed (B) in a client receiving heparin is a sign of heparin toxicity and requires immediate action. It indicates that the client is at risk of excessive bleeding. While a prolonged aPTT of 70 seconds (A) is worth monitoring, active bleeding takes precedence. Elevated blood pressure (C) and lightheadedness (D) are potential side effects of heparin but are not as urgently concerning as active bleeding.

4. During a 30-second interval, the nurse counts six respirations, and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. What respiratory rate should the nurse document?

• A. 14
• B. 16
• C. 17
• D. 28

Correct answer: B

Rationale: The nurse should document a respiratory rate of 16. The second count of eight respirations in a 30-second interval is the most accurate as it was not interrupted by the client coughing. Therefore, this rate reflects the client's typical respiratory pattern and should be documented. Choices A, C, and D are incorrect as they do not consider the interruption caused by the client coughing during the first count, which could have affected the accuracy of the result. The second count of eight respirations provides a more reliable indication of the client's respiratory rate.

5. A client is receiving intravenous (IV) fluids postoperatively. Which assessment finding should prompt the nurse to stop the infusion and notify the healthcare provider?

• A. The client reports pain at the IV site
• B. The client’s blood pressure is elevated
• C. The client has swelling at the IV site
• D. The client’s heart rate is irregular

Correct answer: C

Rationale: Swelling at the IV site may indicate infiltration or phlebitis, which requires stopping the IV infusion and notifying the healthcare provider. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing swelling and potential damage. It is crucial to act promptly to prevent further complications and ensure the client's safety.

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