NCLEX-RN
Female Reproductive System NCLEX RN Questions Questions
Extract:
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 4 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Question 1 of 5
The nurse reviews the diagnostic and laboratory results. For each potential nursing intervention, click to specify whether the Nurses' Notes intervention is indicated or not indicated for the care of the client.
| potential nursing intervention | indicated | not indicated |
|---|---|---|
| obtain an order for serum type and screen | ||
| obtain a prescription for protamine sulfate | ||
| perform neurological assessments every 15 minutes | ||
| obtain a prescription for andexanet | ||
| obtain a prescription to transfuse platelets | ||
| obtain a prescription for ketorolac | ||
| monitor the client for signs and symptoms of increased intracranial pressure |
Correct Answer: A, C, D, G (indicated); B, E, F (not indicated)
Rationale: Indicated: Serum type and screen for potential transfusion, frequent neurological assessments, andexanet for warfarin reversal, and monitoring for increased intracranial pressure due to subarachnoid hemorrhage. Not indicated: Protamine sulfate (for heparin, not warfarin), platelet transfusion (platelets mildly low), ketorolac (contraindicated due to bleeding risk).
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