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).

Answer explanation

Option 1: Ensure that the patient’s mean arterial pressure (MAP) is less than 90 mm Hg.

Option 2: Lower the head of the bed to less than 15 degrees.

Option 3: Encourage visitation.

Option 4: Reassess the patient’s ABCs (airway, breathing, and circulation).

Correct Option: 4

Explanation: The nurse should always reassess the patient's ABCs when ICP is elevated (normal 0–15 mm Hg). The MAP should be maintained ≥90 mm Hg, head elevated 15–30°, and visitors may increase ICP.

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

Answer explanation

Option 1: Deep cyanosis

Option 2: Clubbing of the fingers and toes

Option 3: Loud cardiac murmur

Option 4: Diminished femoral pulses

Correct Option: 4

Explanation: Coarctation is acyanotic, characterized by diminished femoral and bounding upper pulses. Cyanosis and clubbing suggest cyanotic defects.

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

Answer explanation

Option 1: Place the implant in a biohazard bag and return it to the lab

Option 2: Give the client a pair of gloves and ask her to reinsert the implant

Option 3: Use tongs to pick up the implant and return it to a lead-lined container

Option 4: Discard the implant in the commode and double-flush

Correct Option: 3

Explanation: Radioactive implants must be picked up with tongs and returned to lead-lined containers; client must not handle them.

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

Answer explanation

Option 1: Divide the amount into two injections and administer in each vastus lateralis muscle

Option 2: Give the medication in one injection in the dorsogluteal muscle

Option 3: Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle

Option 4: Give the medication in one injection in the ventrogluteal muscle

Correct Option: 1

Explanation: Vastus lateralis is appropriate in infants; no more than 1 mL per injection. Dorsogluteal and ventrogluteal sites are avoided in infants.

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

Answer explanation

Option 1: Dry, pale areas with no blister formation

Option 2: Blisters of varying sizes, with areas of charred tissue

Option 3: Cherry-red areas with weeping blisters

Option 4: Pearly-white areas with charred tissue

Correct Option: 3

Explanation: Deep partial-thickness burns appear cherry-red with fluid-oozing blisters. Pale/charred tissue is full-thickness; superficial burns have smaller blisters.

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

Answer explanation

Option 1: Urinary retention

Option 2: Heart failure

Option 3: Drowsiness

Option 4: Sedation

Correct Option: 2

Explanation: Heart failure is a life-threatening complication of hyperthyroidism. Sedation and drowsiness are less typical; urinary retention isn’t associated.

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

Answer explanation

Option 1: Treat iron-deficiency anemia caused by chemotherapeutic agents

Option 2: Create a synergistic effect that shortens treatment time

Option 3: Increase the number of circulating neutrophils

Option 4: Reverse drug toxicity and prevent tissue damage

Correct Option: 4

Explanation: Methotrexate is a folic acid antagonist; leucovorin reverses its toxicity and limits 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

Answer explanation

Option 1: Occasional hemoptysis

Option 2: Midline trachea with wheezing on auscultation

Option 3: Subcutaneous air and absent breath sounds

Option 4: Pain while deep breathing, with rales in the upper lobes

Correct Option: 3

Explanation: Absent breath sounds and subcutaneous air suggest pneumothorax, which needs urgent intervention.

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.

Answer explanation

Option 1: Identify and evaluate the client promptly.

Option 2: Instruct the client to cover the mouth and nose with tissues when sneezing or coughing.

Option 3: Isolate the client in a negative pressure room.

Option 4: Place a surgical mask on the client.

Correct Option: 1

Explanation: Prompt identification/evaluation is first priority in TB symptoms. Protective measures and isolation follow.

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

Answer explanation

Option 1: Vomiting shortly after eating

Option 2: Epigastric pain following meals

Option 3: Frequent bouts of diarrhea

Option 4: Presence of blood in the stools

Correct Option: 4

Explanation: Melena (blood in stool) is typical in duodenal ulcers. Vomiting and post-meal pain suggest gastric ulcers; diarrhea is not a usual symptom.