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
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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.
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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.”
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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
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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
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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
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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)
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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
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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
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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
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