Rasmussen College MDC 4 Exam 1 Questions and Answers (Verified Answers) 50 Qs - 6 or 7 SATA; 3 or 4 Dose Calc; 1. . A nurse is assessing a client in postoperative recovery. The client com- plains of the following symptoms. Which of the following is abnormal and should be reported immediately? a. Emesis that is red b. Complaint of feeling cold c. Nausea d. Complaint of pain ANS a. Emesis that is red 2. A client's neurological status deteriorates over hours, and a craniotomy is performed to evacuate a hematoma. Which nursing intervention is indicated to help de- crease the threat of increased intracranial pressure? a. Elevate the head of the bed 30 degrees b. Cluster nursing interventions to provide uninterrupted periods of rest c. Teach the client to cough and deep breathe to prevent the necessity for suctioning d. Teach the client to hold his breath and bear down while repositioning in bed. ANS a. Elevate the head of the bed 30 degrees 3. A client presents to the emergency room with complaints of bilateral lower extremity loss of sensation that started in the feet but has now progressed to the knees and hips. The nurse interprets these symptoms to indicate an immediate workup for which of the following diseases? a. Myasthenia gravis b. Simple, partial seizure c. Guillain-Barre Syndrome d. Cerebrovascular accident ANS c. Guillain-Barre Syndrome 4. The charge nurse is obtaining the client's signature on a surgical consent form. The client states, I didn't really understand what my surgeon explained, but I trust him completely, which response by the charge nurse is correct? a. I need to contact your surgeon so your questions can be answered b. I can answer any questions that you might have regarding your surgery. c. As long as you are comfortable, then you may sign the consent form. d. Maybe you should call your surgeon to be sure it is okay to sign the consent. ANS a. I need to contact your surgeon so your questions can be answered 5. A client has a head injury and is presenting with signs and symptoms of increased intracranial pressure. Which nursing intervention would be helpful in reducing this pressure? a. Place the neck in a neutral position to promote venous drainage b. Suction hourly to stimulate the cough reflex c. Add extra blankets to keep the client warm. d. Turn the client frequently to prevent skin impairment ANS a. Place the neck in a neutral position to promote venous drainage 6. A client has recently suffered a stroke with left-sided weakness. The nurse assesses for dysphagia, especially with thin liquids. Which nursing intervention is most helpful in assisting this patient to swallow safely? a. The client should avoid all liquids. b. Instructing to tuck the chin when swallowing c. Give sips of water with each bite d. Turn head to the left. ANS b. Instructing to tuck the chin when swallowing 7. A client has a comminuted fracture of T6-T7, resulting in paraplegia. The nurse educates the client on preventing autonomic dysreflexia. Which of the following is the priority intervention in this medical emergency? a. Scheduled bladder and bowel training b. Choosing foods to prevent nausea c. Avoiding food allergies d. Preventing electrolyte imbalances ANS a. Scheduled bladder and bowel training 8. The nurse develops a care plan for a client recover ing from surgery. What nursing
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