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Questions, Interventions, Clinical Experience and INR

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NCLEX Questions
1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
A. Reposition the client to avoid neck flexion
B. Administer 1 g Manito IV as ordered
C. Increase the ventilator’s respiratory rate 10 to 20 breaths/minute
D. Administer 100mg of pentobarbital IV as ordered.
Answer A
2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
A. Therapeutic drug levels should be maintained between 20 to 30 mg/ml.
B. Rapid Dilantin administration can cause cardiac arrhythmias.
C. Dilantin should be mixed in dextrose in water before administration.
D. Dilantin should be administered through an IV catheter in the client’s hand.
Answer B
3. A client with head trauma develops a urine output of 300 ml/hr., dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
A. Evaluate urine specific gravity
B. Anticipate treatment for renal failure
C. Provide emollients to the skin to prevent breakdown
D. Slow down the IV fluids and notify the physician
Answer A
4. When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?
A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
B. Emergent; the client is poorly oxygenated.
C. Normal
D. Significant; the client has alveolar hypoventilation.
Answer A
5. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs?
A. Bloody drainage from the ears
B. Frequent swallowing
C. Guaiac-positive stools
D. Hematuria
Answer B
Clinical Experience
My last clinical experience was at Catawba Pediatrics. I saw a lot of respiratory infections, ear infections and strep throat. We encouraged the children as well as their parents to be consistent with their hand washing and eating a healthy diet. It is prime season to be weary of these diseases. I was able to give a couple of IM Injections; which made me feel more competent.

Cellular Regulation- Impaired Gas Exchange
1. Encourage frequent position changes, coughing and deep-breathing exercises with incentive spirometer, chest physiotherapy- promotes optimal chest expansion and drainage of secretions.
2. Encourage client and significant other to stop smoking- to reduce health risks and/or prevent further decline in lung function.
3. Maintain adequate intake and output- help with mobilization of secretions but avoid fluid overload.
Perfusion: Ineffective Peripheral Tissue Perfusion
1. Monitor peripheral pulses. If there is new onset of loss of pulses with bluish, purple or black areas and extreme pain, notify the physician immediately- These are symptoms of arterial obstruction that can result in loss of a limb if not immediately reversed.
2. Check capillary refill- Nail beds usually return to a pinkish color within 2-3 seconds after nail bed compression.
3. Do not elevate the legs above the level of the heart- With arterial insufficiency, leg elevation decreases arterial blood supply to the legs.evate the legs above the level of the heart- With arterial insufficiency, leg elevation decreases arterial blood supply to the legs.
INR
If a patient had an INR of 4 the patient would be taking Coumadin.
1. Check VS, platelet counts, and PT-Monitor bleeding and clotting time.
2. No green, leafy vegetables-They increase the risk of clotting time.
3. Observe for gums that bleed or ecchymosis- indications of too much Coumadin.




Last edited by avasmorrison on Tue Nov 15, 2011 6:00 pm; edited 1 time in total

Guest


Guest
I'm glad you were able to give some IM injections. It always seems like there are things in clinical that we need more practice on and that is one of them. I would also like more practice on starting IVs. Your NCLEX questions were great!

Guest


Guest
When I was preparing to give my first injection to a peds pt my thought was whether I would hit the bone since his arm was so small. I was glad they were friendly and encouraged learning by giving hints on how to hold the arm secure and also be able to complete the injection without doing damage.

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