Difficulty: Medium
Average Score: 82%
Simulated
Passage / Scenario
Vital signs0600:
Temperature 37.2┬░ C (99┬░ F)
Heart rate 66/min
Respiratory rate 16/min
BP 130/82 mm Hg
Pulse oximetry 96% on room air
1000:
Temperature 37.6┬░ C (99.7┬░ F)
Heart rate 70/min
Respiratory rate 20/min
BP 160/102 mm Hg
Pulse oximetry 96% on room air
Client reports pain as 10 on a scale of 0 to 10 from headache
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
Correct answer
C,E
Rationale
[0,0,1,0,1,0,0]
Performing suctioning is not indicated unless there is a clear need for airway clearance. Withholding pain medication (option B) for headache may worsen the client's discomfort. Administering nifedipine (option D) should not be done without proper assessment and prescription. Placing the client in the supine position (option F) may not be ideal depending on the client's condition. Assessing blood pressure (option C) is important for monitoring the client's status, especially after a head injury. Assessing for urinary retention (option E) is also crucial to ensure proper bladder function and prevent complications.
Performing suctioning is not indicated unless there is a clear need for airway clearance. Withholding pain medication (option B) for headache may worsen the client's discomfort. Administering nifedipine (option D) should not be done without proper assessment and prescription. Placing the client in the supine position (option F) may not be ideal depending on the client's condition. Assessing blood pressure (option C) is important for monitoring the client's status, especially after a head injury. Assessing for urinary retention (option E) is also crucial to ensure proper bladder function and prevent complications.