A client has a subarachnoid bolt. What action by the nurse is most important?
a. Balancing and recalibrating the device
b. Documenting intracranial pressure readings
c. Handling the fiberoptic cable with care to avoid breakage
d. Monitoring the client's phlebostatic axis
ANS: A
This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the device's accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the device's accuracy is most important. The phlebostatic axis is not related to neurologic monitoring.
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Prenatal testing is used to assess for genetic risks and to identify genetic disorders. In discussing an elevated alpha-fetoprotein screening test result with a couple, the nurse would discuss:
A) The special care needed for a Down syndrome infant B) The need for a more specific determination of the acid–base status C) The need for more definitive evaluations before making any conclusions D) The need for immediate termination of the pregnancy
A mentally ill client is accused of a nonviolent crime and is arrested by law enforcement. What type of program would offer an alternative to incarceration?
A) Intensive outpatient treatment B) Inpatient hospitalization C) Mental health court D) Day treatment
A signal that bleeding is occurring in the respiratory tract is blood in the sputum or ________.
Fill in the blank(s) with the appropriate word(s).
T.M. returns to your unit the next afternoon from the postanesthesia care unit (PACu). He is in a bilateral
spica cast, has a Foley catheter, and has a family-controlled patient-controlled analgesia (PCA) device for pain control. You assess T.M. and chart the following findings. What are your top five priorities while providing nursing care to T.M. postoperatively? How will you address these areas?