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Question 1 of 5

The nurse is caring for a client in intensive care with a diagnosis of traumatic brain injury. The client is found to be restless, complains of extreme nausea, and is weak on the left arm and leg. Which is the best response by the nurse?

Correct Answer: B

Rationale: Elevating the head to 30 degrees reduces intracranial pressure in traumatic brain injury, addressing symptoms like nausea and restlessness.

Question 2 of 5

The nurse is preparing a middle-aged female for a total knee replacement (TKR) surgery on her left leg tomorrow. Which statement by the nurse is incorrect?

Correct Answer: C

Rationale: A fracture pan is inappropriate post-TKR; a bedpan or bedside commode is typically used. Other statements are correct.

Question 3 of 5

The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?

Correct Answer: C

Rationale: Aspirin increases bleeding risk when taken with warfarin, indicating a need for further teaching to avoid this combination.

Question 4 of 5

In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:

Correct Answer: D

Rationale: Pitocin is effective if it promotes progressive cervical dilation, correcting secondary dystocia.

Question 5 of 5

The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

Correct Answer: C

Rationale: A heart rate of 60 bpm in a 6-month-old is too low (normal is 80-160 bpm), indicating possible digitalis toxicity, which should be reported.

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