ATI MED SURG TEST BANK Q&A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experien... cing increased ICP? a. Flat jugular veins b. GCS score of 15 c. Sleepiness exhibited by the client d. Widening pulse pressure e. Decerebrate posturing f. Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended. A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15 indicates neurological functioning within the expected reference range for eye opening, motor, and verbal response. Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP. Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of increased ICP. Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased ICP. 2. A nurse is preparing a client who hassupraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the clients to withhold for 48hr prior to cardioversion? a. Enoxaparin b. Metformin c. Diazepam d. Digoxin e. Anticoagulants can be beneficial during cardioversion due to their ability to prevent blood clots that can be released into the client's circulatory system after cardioversion. This medication should not be withheld. f. Metformin g. Metformin might be withheld for a client scheduled for cardiac catheterization or other procedures involving contrast dye in order to prevent damage to the kidneys. However, metformin should not be withheld prior to cardioversion. h. Diazepam i. Sedatives are generally administered to clients prior to cardioversion to reduce anxiety and minimize the discomfort associated with the procedure. This medication should not be withheld. j. Digoxin: ANSWER k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion. 3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s priority? Anorexia a. Abdominal pain radiating to the right shoulder b. Tachycardia c. Rebound abdominal tenderness i. Anorexia ii. Anorexia is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority. iii. Abdominal pain radiating to the right shoulder iv. MY ANSWER v. Abdominal pain radiating to the right shoulder is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority. vi. Tachycardia vii. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider. viii. Rebound abdominal tenderness ix. Rebound abdominal tenderness is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority. 4. A nurse is preparing to admit a client who has dysphagia. The nurse should plant to place which of the following items at the client’s bedside? a. Suction machine b. Wire cutters c. Padded clamp d. Communication board e. Suction machine: ANSWERThe nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration. f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a client who has an inner maxillary fixation to cut the wires in case the client vomits. This enables the client to clear their airway and reduce the risk for aspiration. g. Padded clamp: The nurse should ensure a padded clamp is at the bedside of a client who has a chest tube to clamp the tube and prevent air from entering the [Show More]
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