Nursing Intervention Guidelines
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Questions and Answers

What is the appropriate method for measuring a client for crutches after a motorcycle accident?

  • Measure the client with the crutches 20 inches from the side of the foot
  • Measure the client with the elbows flexed 10°
  • Measure five finger breadths under the axilla (correct)
  • Measure 3 inches under the axilla
  • Which area of the brain is responsible for the senses of taste, smell, and hearing?

  • Temporal (correct)
  • Frontal
  • Occipital
  • Parietal
  • What is the most likely explanation for an elevated temperature of 102°F in a patient after a motor vehicle accident?

  • There was damage to the hypothalamus
  • He has an infection from the abrasions to the head and face (correct)
  • He will require a cooling blanket to decrease the temperature
  • There was damage to the frontal lobe of the brain
  • Why is a low-protein diet ordered for a client with chronic renal failure?

    <p>Protein breaks down into blood urea nitrogen and other waste</p> Signup and view all the answers

    When administering heparin for thrombophlebitis, which method should be used?

    <p>Three-way stop-cock</p> Signup and view all the answers

    What result will occur if the blood pressure cuff is too small for an obese client?

    <p>A false elevation</p> Signup and view all the answers

    Which intervention is appropriate for a 4-year-old male with nephrotic syndrome experiencing scrotal edema?

    <p>Apply ice to the scrotum</p> Signup and view all the answers

    What should be reported to the doctor for a client with an abdominal aortic aneurysm?

    <p>An elevated white blood cell count</p> Signup and view all the answers

    If the deep tendon reflexes of the patella cannot be elicited, the nurse should ask the client to:

    <p>Pull against the palms</p> Signup and view all the answers

    What does the evaluation of pulmonary artery pressure assess?

    <p>The systolic, diastolic, and mean pressure of the pulmonary artery</p> Signup and view all the answers

    If a central venous pressure monitor reads 2cm of water, what should the nurse do?

    <p>Listen to the lungs for rales</p> Signup and view all the answers

    What should the nurse do upon identifying ventricular tachycardia on the heart monitor?

    <p>Prepare to administer an antiarrhythmic such as lidocaine</p> Signup and view all the answers

    In preparation for the removal of chest tubes, what instruction should the nurse give to the client?

    <p>Hold his breath and bear down</p> Signup and view all the answers

    Study Notes

    Crutch Measurement

    • Measure crutches five finger breadths under the axilla for proper fit.

    Brain Functions

    • Temporal lobe is responsible for taste, smell, and hearing functions.

    Elevated Temperature After Accident

    • Elevated temperature following a motor vehicle accident may indicate infection from abrasions or damage to the hypothalamus.

    Chronic Renal Failure Diet

    • A low-protein diet is recommended for chronic renal failure because protein breakdown leads to increased blood urea nitrogen and waste products.

    Heparin Administration

    • Heparin should be administered using an intravenous filter to ensure safe delivery of the medication.

    Blood Pressure Cuff Size

    • Using a blood pressure cuff that is too small can cause a false elevation in blood pressure readings.

    Scrotal Edema in Nephrotic Syndrome

    • Elevate the scrotum on a small pillow to alleviate discomfort associated with severe scrotal edema in nephrotic syndrome.

    Abdominal Aortic Aneurysm Signs

    • An elevated white blood cell count should be reported to the doctor when preparing a patient for surgery on an abdominal aortic aneurysm.

    Deep Tendon Reflex

    • If unable to elicit the patellar reflex, the client should cross their legs at the ankles to facilitate response.

    Atropine Administration Calculation

    • To administer 0.4mg of atropine sulfate supplied at 0.8mg/mL, administer 0.5mL of the medication.

    Pulmonary Artery Pressure Evaluation

    • Pulmonary artery pressure evaluation provides data on systolic, diastolic, and mean pressures within the pulmonary artery.

    Central Venous Pressure Monitoring

    • If central venous pressure reads 2cm of water, the nurse should listen for lung rales for potential complications.

    Ventricular Tachycardia Response

    • In case of ventricular tachycardia, prepare to administer antiarrhythmics, like lidocaine, for immediate intervention.

    Chest Tube Removal Instructions

    • The patient should be instructed to hold their breath and bear down when preparing for chest tube removal to prevent air intake.

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    Description

    This quiz covers essential nursing interventions, including proper fitting of crutches, dietary recommendations for chronic renal failure, and methods for administering heparin. Additionally, it addresses vital signs monitoring, such as blood pressure and the management of scrotal edema in nephrotic syndrome. Test your knowledge of these critical nursing practices.

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