Paramedics have brought an intubated patient to the emergency department following a head injury due to acceleration-deceleration motor vehicle accident. Increased intracranial pressure (ICP) is suspected
An appropriate nursing intervention would include what?
A) Keep the head of bed (HOB) flat at all times
B) Teach the patient to perform the Valsalva maneuver
C) Administer antipyretics on a p.r.n. basis
D) Perform endotracheal suctioning every hour
C
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The nurse is caring for a patient who has had a chest tube in place for 2 days. As the nurse begins her shift assessment, she should ensure that what equipment is at the bedside? (Select all that apply.)
a. Two rubber-tipped clamps b. Plain gauze 4 ? 4 c. Sterile petroleum gauze d. Extra drainage system e. A sterile chest tube of the same size as the one inserted in the patient
Immediately after the forceps-assisted birth of an infant, the nurse should:
a. Assess the infant for signs of trauma. b. Give the infant prophylactic antibiotics. c. Apply a cold pack to the infant's scalp. d. Measure the circumference of the infant's head.
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action?
a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears.
What technique should the nurse use to implement infection control in the home?
A) Avoid touching any object in the home, including door knobs. B) Practice hand hygiene when beginning and ending the home visit. C) Wear gloves at all times when in the home or traveling in the car. D) Take prescribed antibiotics on a regular basis on working days.