GCC 1 - 25

For a patient whose ICP fluctuates between 20 and 25 mm Hg, which nursing intervention would be most appropriate?

• Ensure that the patient’s mean arterial pressure (MAP) is less than 90 mm Hg.
• Lower the head of the bed to less than 15 degrees.
• Encourage visitation.
• Reassess the patient’s ABCs (airway, breathing, and circulation).
• -

The nurse is assessing an infant with coarctation of the aorta. The nurse can expect to find:

• Deep cyanosis
• Clubbing of the fingers and toes
• Loud cardiac murmur
• Diminished femoral pulses
• -

While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:

• Place the implant in a biohazard bag and return it to the lab
• Give the client a pair of gloves and ask her to reinsert the implant
• Use tongs to pick up the implant and return it to a lead-lined container
• Discard the implant in the commode and double-flush
• -

The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:

• Divide the amount into two injections and administer in each vastus lateralis muscle
• Give the medication in one injection in the dorsogluteal muscle
• Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle
• Give the medication in one injection in the ventrogluteal muscle
• -

When assessing the skin of a patient with deep partial-thickness burns, what would the nurse expect to find?

• Dry, pale areas with no blister formation
• Blisters of varying sizes, with areas of charred tissue
• Cherry-red areas with weeping blisters
• Pearly-white areas with charred tissue
• -

The nurse is caring for a client with hyperthyroidism. Which clinical manifestation should be reported to the physician immediately?

• Urinary retention
• Heart failure
• Drowsiness
• Sedation
• -

A client with rheumatoid arthritis is receiving Methotrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:

• Treat iron-deficiency anemia caused by chemotherapeutic agents
• Create a synergistic effect that shortens treatment time
• Increase the number of circulating neutrophils
• Reverse drug toxicity and prevent tissue damage
• -

The nurse is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment findings include a respiratory rate of 40, a heart rate of 126, and restlessness. Which associated assessment finding would require immediate intervention?

• Occasional hemoptysis
• Midline trachea with wheezing on auscultation
• Subcutaneous air and absent breath sounds
• Pain while deep breathing, with rales in the upper lobes
• -

Many persons with active tuberculosis (TB) often first present in ambulatory care settings. What is the first action that should be taken in caring for a client with symptoms of tuberculosis?

• Identify and evaluate the client promptly.
• Instruct the client to cover the mouth and nose with tissues when sneezing or coughing.
• Isolate the client in a negative pressure room.
• Place a surgical mask on the client.
• -

Which one of the following symptoms is common in the client with duodenal ulcers?

• Vomiting shortly after eating
• Epigastric pain following meals
• Frequent bouts of diarrhea
• Presence of blood in the stools
• -