NCLEX-RN
NCLEX RN Neurological Questions Questions
Extract:
The following scenario applies to the next 1 items
The intensive care unit nurse has completed the assessment of a client
Item 1 of 1
Nurses' Notes
Progress Notes Orders
Day 2
1445: Physician at the bedside. The client is sedated, receiving mechanical ventilation via the #8 endotracheal tube. Current ventilator settings: assist control; rate 12/minute; tidal volume 450 mL; FiO 2 100%; positive end-expiratory pressure (PEEP) 5 cm H20. Intraventricular catheter present and zeroed and calibrated. No purposeful movement, and pupils were 3 mm equally round and sluggish to light. No abnormal posturing. + gag reflex; + corneal reflex. Lung sounds clear bilaterally, and the chest rises and falls synchronously with the ventilator. Peripheral pulses 2+ and S1 and S2 heart tones. Normoactive bowel sounds in all quadrants, no abdominal distention. Skin warm and dry. Indwelling urinary catheter patent and draining clear, concentrated urine. The client is currently positioned in a semi-Fowler position.
The nurse reviews the physician's orders
Question 1 of 5
Click to specify if the order is indicated or requires follow-up with the physician:
| Physician Order | Indicated | Requires Follow-up |
|---|---|---|
| 0.45% saline infusion | ||
| increase PEEP to 15 cm H20 | ||
| enoxaparin subcutaneously | ||
| levetiracetam intravenous piggy-back | ||
| pneumatic compression devices to the lower extremities | ||
| repeated computed tomography (CT) scan |
Correct Answer: B,B,B,A,A,A
Rationale: Hypotonic saline (0.45%) may worsen cerebral edema in brain injury; isotonic saline is preferred.
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Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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