GCC 501 - 525

Which one of the following assessment findings is within normal expectations for a post-operative craniotomy client?

• A decrease in responsiveness the third post-op day
• Sluggish pupil reaction the first 24–48 hours
• Dressing changes 3–4 times a day for the first 3 days
• Temperature range of 98.8°F–99.6°F the first 2–3 days
• -

Answer explanation

Option 1: A decrease in responsiveness the third post-op day

Option 2: Sluggish pupil reaction the first 24–48 hours

Option 3: Dressing changes 3–4 times a day for the first 3 days

Option 4: Temperature range of 98.8°F–99.6°F the first 2–3 days

Option 5: -

Correct Option: Option 4 – Temperature range of 98.8°F–99.6°F the first 2–3 days

Explanation: A slight elevation in temperature would be expected from surgical intervention and would not be a cause for concern. Answers A, B, and C could indicate a progressing complication, so they are incorrect.

The nurse inserts an indwelling urinary catheter in a client. Which nursing intervention is most likely to prevent a urinary tract infection?

• Restricting fluid intake.
• Cleaning the perineal area and urinary meatus twice a day and as needed.
• Obtaining specimens by disconnecting the tube from the drainage bag.
• Irrigating the catheter with saline twice a day and as needed.
• -

Answer explanation

Option 1: Restricting fluid intake.

Option 2: Cleaning the perineal area and urinary meatus twice a day and as needed.

Option 3: Obtaining specimens by disconnecting the tube from the drainage bag.

Option 4: Irrigating the catheter with saline twice a day and as needed.

Option 5: -

Correct Option: Option 2 – Cleaning the perineal area and urinary meatus twice a day and as needed.

Explanation: Ensuring that the perineal area and urinary meatus are clean can prevent urinary tract infections. Restricting fluid intake can increase the risk of infection, as can opening up the drainage system when collecting specimens. Irrigating the catheter prevents obstruction, but requires a physician’s order.

A woman who is Rh-negative has delivered an Rh-positive infant. The nurse explains to the client that she will receive RhoGAM. The nurse determines that the client understands the purpose of RhoGAM when she states:

• “RhoGAM will protect my next baby if it is Rh-negative.”
• “RhoGAM will prevent antibody formation in my blood.”
• “RhoGAM will be given to prevent German measles.”
• “RhoGAM will be used to prevent bleeding in my newborn.”
• -

Answer explanation

Option 1: “RhoGAM will protect my next baby if it is Rh-negative.”

Option 2: “RhoGAM will prevent antibody formation in my blood.”

Option 3: “RhoGAM will be given to prevent German measles.”

Option 4: “RhoGAM will be used to prevent bleeding in my newborn.”

Option 5: -

Correct Option: Option 2 – “RhoGAM will prevent antibody formation in my blood.”

Explanation: RhoGAM is given to new mothers who are Rh-negative and not previously sensitized and who have delivered an Rh-positive infant. RhoGAM must be given within 72 hours of the delivery of the infant because antibody formation begins at that time. The vaccine is used only when the mother delivered an Rh-positive infant—not an Rh-negative infant. RhoGAM does not prevent German measles and is not given to a newborn.

What would the nurse expect to see included in the treatment plan of a 14-year-old with scoliosis and an 18° curvature of the spine?

• Application of a Milwaukee brace
• Electrical stimulation to the outward side of the curve
• Re-evaluation with no treatment at this time
• Surgical realignment of the spine
• -

Answer explanation

Option 1: Application of a Milwaukee brace

Option 2: Electrical stimulation to the outward side of the curve

Option 3: Re-evaluation with no treatment at this time

Option 4: Surgical realignment of the spine

Option 5: -

Correct Option: Option 3 – Re-evaluation with no treatment at this time

Explanation: If a client has a curvature of less than 20°, it is considered mild, with no treatment required. If after reevaluation the curve is progressing, treatment might be necessary. Answer A and B are done with curvatures greater than 20°, so they are incorrect. Answer D might be required with curvatures greater than 40°, which makes it incorrect.

The nurse is caring for a client with a T4 spinal cord injury when he begins to have symptoms of autonomic dysreflexia. After placing the client in high Fowler’s position, the nurse should:

• Administer a prescribed analgesic
• Check for patency of the catheter
• Tell the client to breathe slowly
• Check the temperature
• -

Answer explanation

Option 1: Administer a prescribed analgesic

Option 2: Check for patency of the catheter

Option 3: Tell the client to breathe slowly

Option 4: Check the temperature

Option 5: -

Correct Option: Option 2 – Check for patency of the catheter

Explanation: Symptoms of autonomic dysreflexia are often triggered by bladder distention or fecal impaction; therefore, after raising the client’s head, the nurse should check for patency of the catheter. Answer A is incorrect because administering a prescribed analgesic will not alleviate the symptoms of autonomic dysreflexia. Answer C is incorrect because breathing slowly does not alleviate autonomic dysreflexia. Answer D is incorrect because the changes in the client’s temperature are not associated with autonomic dysreflexia.

A 66-year-old patient has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. He is tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. This patient has signs and symptoms of which respiratory disorder?

• ARDS
• Asthma
• Chronic obstructive bronchitis
• Emphysema
• -

Answer explanation

Option 1: ARDS

Option 2: Asthma

Option 3: Chronic obstructive bronchitis

Option 4: Emphysema

Option 5: -

Correct Option: Option 4 – Emphysema

Explanation: These are classic signs and symptoms of a patient with emphysema. Patients with ARDS (Option A) are acutely short of breath and require emergency care; those with asthma (option B) are also acutely short of breath during an attack and appear very frightened. Patients with chronic obstructive bronchitis (Option C) appear bloated and cyanotic.

A client with acute pancreatitis has requested pain medication. Which pain medication is indicated for the client with acute pancreatitis?

• Demerol (meperidine)
• Toradol (ketorolac)
• Morphine (morphine sulfate)
• Codeine (codeine)
• -

Answer explanation

Option 1: Demerol (meperidine)

Option 2: Toradol (ketorolac)

Option 3: Morphine (morphine sulfate)

Option 4: Codeine (codeine)

Option 5: -

Correct Option: Option 1 – Demerol (meperidine)

Explanation: To prevent spasms of the sphincter of Oddi, the client with acute pancreatitis should receive non-opiate analgesics for pain. Answer B is incorrect because the client with acute pancreatitis might be prone to bleed; therefore, Toradol is not a drug of choice for pain control. Morphine and codeine, opiate analgesics, are contraindicated for the client with acute pancreatitis; therefore, answers C and D are incorrect.

The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:

• Notify her doctor
• Document the finding
• Reposition the client
• Readjust the monitor
• -

Answer explanation

Option 1: Notify her doctor

Option 2: Document the finding

Option 3: Reposition the client

Option 4: Readjust the monitor

Option 5: -

Correct Option: Option 3 – Reposition the client

Explanation: The initial action by the nurse observing a variable deceleration should be to turn the client to the side, preferably the left side. Administering oxygen is also indicated. Answer A is incorrect because the question asks for the initial action. The initial action should be to turn the client to her side. If this does not resolve the problem, call the doctor. Answers B and D are incorrect because there is no data to indicate that the monitor is applied incorrectly.

A patient, age 39, has type 1 diabetes mellitus. When he arrives at the ED complaining of dizziness, the nurse notes that he seems weak, confused, and disoriented. His wife states that he took his usual morning dose of 6 units of regular insulin and 15 units of NPH insulin, but ate little of his breakfast. What is the most likely cause of the patient’s signs and symptoms?

• Ketoacidosis
• Hyperglycemia
• Hyperlipidemia
• Hypoglycemia
• -

Answer explanation

Option 1: Ketoacidosis

Option 2: Hyperglycemia

Option 3: Hyperlipidemia

Option 4: Hypoglycemia

Option 5: -

Correct Option: Option 4 – Hypoglycemia

Explanation: Dizziness, weakness, confusion, and disorientation signal an insulin reaction and severe hypoglycemia—a common finding in diabetic patients who take insulin but miss a meal. Ketoacidosis (Option A) and hyperglycemia (Option B) are rare in a patient with diabetes who takes insulin and decreases his nutritional intake. Option C is incorrect because hyperlipidemia (an excessive blood fat level) doesn’t cause hypoglycemia.

The nurse is caring for a patient with active upper-GI bleeding. What is the appropriate diet for this patient during the first 24 hours after admission?

• Regular diet
• Skim milk
• Nothing by mouth
• Clear liquids
• -

Answer explanation

Option 1: Regular diet

Option 2: Skim milk

Option 3: Nothing by mouth

Option 4: Clear liquids

Option 5: -

Correct Option: Option 3 – Nothing by mouth

Explanation: Shock and bleeding must be controlled before oral intake begins, so the patient should receive nothing by mouth. A regular diet (Option A) is incorrect. When the bleeding is controlled, intake is gradually increased, starting with ice chips and then clear liquids. Skim milk (Option B) is incorrect because it increases gastric acid production that could prolong the bleeding. A clear liquid diet (Option D) is the first diet offered after bleeding and shock are controlled.