The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg
The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning.
b. Elevate the patient's head of the bed 30 degrees.
c. Apply bilateral heel protectors after repositioning.
d. Provide rest periods between nursing interventions.
D
Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patient's plan of care; however, spacing out interventions is the priority.
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Regardless of the mother's hepatitis B surface antigen status, all newborns should receive their first vaccination against hepatitis B:
a. Within 12 hours of birth b. At 1 year of age c. At 6 months of age d. At 6 years of age
The nurse suspects that a client is experiencing fibromyalgia. What findings did the nurse use to come to this conclusion? (Select all that apply.)
1. Fatigue 2. Headaches 3. Blurred vision 4. Muscle spasms 5. Painful trigger points in the neck and shoulders
A client with asthma as well as a musculoskeletal disorder is prescribed calcium carbonate as treatment for the musculoskeletal disorder. What advice, related to the intake of calcium carbonate, should the nurse give to the client?
A) Take other drugs 1 to 2 hours after taking calcium carbonate. B) Avoid performing strenuous activity for 1 to 2 hours after taking calcium carbonate. C) Take calcium carbonate before bedtime. D) Ingest calcium carbonate with plenty of milk.
The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses is discussing its responsibility in relation to bioterrorism
Which statement by the nurse indicates a correct understanding of the concepts presented? 1. "It is important to separate clients according to age and illness to prevent the spread of disease." 2. "It is important to dispose blood-contaminated needles in the lead-lined container." 3. "I will notify the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room." 4. "I will initiate isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA)."