When caring for a client who is post–intracranial surgery what is the most important parameter to monitor?
A) Extreme thirst
B) Intake and output
C) Nutritional status
D) Body temperature
D
Feedback:
It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.
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In evaluating pain for the management of myocardial infarction, the most important aspect using objective data is
a. patient's vital signs during painful periods. b. dilation of the patient's pupils. c. painful expression on the patient's face. d. report of the severity of the pain.
The nurse has provided education for a client prescribed the contraceptive Seasonale. Which statement made by the client indicates an understanding of the information?
A. "After I have taken 21 pills, I will not take pills for 7 days." B. "I will remove the ring at the end of 3 weeks." C. "After I have taken pills for 84 days, I will not take pills for 7 days." D. "I will change the patch each week."
A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action?
A) Document the patient's low urine output and monitor closely for the next several hours. B) Contact the dietitian and suggest the need for increased oral fluid intake. C) Contact the patient's physician and suggest assessment of fluid balance and renal function. D) Increase the infusion rate of the patient's IV fluid to prompt an increase in renal function.
The client diagnosed with acute MI is to receive tenecteplase (TNKase). What is an advan-tage of this therapy over other fibrinolytic drugs?
A. TNKase restores perfusion to coronary arteries. B. TNKase limits damage to the myocardium. C. TNKase decreases mortality in clients with MI. D. TNKase is administered in a single bolus over 5 seconds.