UWorld NCLEX-PN Rationale-based
Study Guide Exam Questions and
Correct Answers/Grade A+ Assured
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Terms in this set (124)
, CORRECT ANSWER: 3
A craniotomy involves incision into the
cranium and is indicated for elevated
intracranial pressure or removal of
The nurse is caring
tumors, blood, or abscesses.
for a client who is
Postoperative clients are at risk for
2 days
developing a cerebrospinal fluid (CSF)
postoperative
leak from an intraoperative dural injury,
craniotomy with
which increases the risk for meningitis.
bone flap removal.
The nurse notes
Excessive drainage from a craniotomy
clear wound
incision (eg, saturated dressing, >50 mL
drainage
per shift into the drain) or from the nose
saturating the
or ear suggests a possible CF leak
dressing over the
requiring immediate notification of the
incision. Which
health care provider (HCP) (Option 3 is
action by the
correct). Interventions focus on
nurse is most
decreasing strain on the dural tear to
appropriate at this
encourage closure and include bedrest,
time?
lumbar drain placement, and surgical
intervention.
1. Cleanse the
incision site with
(Option 1 is wrong) The incision should
saline and apply a
not be re-dressed until the HCP can
new, sterile
evaluate the wound and drainage.
dressing
2. Mark the edges
(Option 2 is wrong) The nurse should
,of the drainage on mark the drainage edges at least once
the dressing and per shift for comparison. However, a
continue to saturated dressing may indicate a CSF
monitor leak.
3. Notify the
health care (Option 4 is wrong) Repositioning may
provider of the be indicated but is not the most
color and amount appropriate action at this time. Specific
of drainage 4. Turn client positioning postoperative
the client onto the craniotomy is prescribed by the HCP.
nonoperative side The head of the bed is usually elevated
using the log- approximately 30 degrees to facilitate
rolling technique venous drainage and prevent increased
intracranial pressure. If flat positioning is
prescribed, the nurse should log-roll
the client to alternate between the back
and the nonoperative side.
, An unlicensed CORRECT ANSWER: 1, 5
assistive personnel
(UAP) is aiding a Adding milk to mashed potatoes will
client recovering alter the consistency; if the consistency
from a right-sided is too thin, the client will be at increased
cerebrovascular risk of aspiration.
accident with
resulting mild Using a straw for drinking liquids might
oropharyngeal cause increased swallowing difficulty
dysphagia. The and choking. Controlling liquid intake
client has been through a straw is more difficult than
placed on a drinking straight from a cup or glass.
dysphagia diet.
Which actions
require
intervention by the
nurse? Select all
that apply.
1. The UAP adds
milk to mashed
potatoes to make
them thinner.
2. The UAP
encourages the
client to
occasionally turn
the head to the
left
Study Guide Exam Questions and
Correct Answers/Grade A+ Assured
Save
Terms in this set (124)
, CORRECT ANSWER: 3
A craniotomy involves incision into the
cranium and is indicated for elevated
intracranial pressure or removal of
The nurse is caring
tumors, blood, or abscesses.
for a client who is
Postoperative clients are at risk for
2 days
developing a cerebrospinal fluid (CSF)
postoperative
leak from an intraoperative dural injury,
craniotomy with
which increases the risk for meningitis.
bone flap removal.
The nurse notes
Excessive drainage from a craniotomy
clear wound
incision (eg, saturated dressing, >50 mL
drainage
per shift into the drain) or from the nose
saturating the
or ear suggests a possible CF leak
dressing over the
requiring immediate notification of the
incision. Which
health care provider (HCP) (Option 3 is
action by the
correct). Interventions focus on
nurse is most
decreasing strain on the dural tear to
appropriate at this
encourage closure and include bedrest,
time?
lumbar drain placement, and surgical
intervention.
1. Cleanse the
incision site with
(Option 1 is wrong) The incision should
saline and apply a
not be re-dressed until the HCP can
new, sterile
evaluate the wound and drainage.
dressing
2. Mark the edges
(Option 2 is wrong) The nurse should
,of the drainage on mark the drainage edges at least once
the dressing and per shift for comparison. However, a
continue to saturated dressing may indicate a CSF
monitor leak.
3. Notify the
health care (Option 4 is wrong) Repositioning may
provider of the be indicated but is not the most
color and amount appropriate action at this time. Specific
of drainage 4. Turn client positioning postoperative
the client onto the craniotomy is prescribed by the HCP.
nonoperative side The head of the bed is usually elevated
using the log- approximately 30 degrees to facilitate
rolling technique venous drainage and prevent increased
intracranial pressure. If flat positioning is
prescribed, the nurse should log-roll
the client to alternate between the back
and the nonoperative side.
, An unlicensed CORRECT ANSWER: 1, 5
assistive personnel
(UAP) is aiding a Adding milk to mashed potatoes will
client recovering alter the consistency; if the consistency
from a right-sided is too thin, the client will be at increased
cerebrovascular risk of aspiration.
accident with
resulting mild Using a straw for drinking liquids might
oropharyngeal cause increased swallowing difficulty
dysphagia. The and choking. Controlling liquid intake
client has been through a straw is more difficult than
placed on a drinking straight from a cup or glass.
dysphagia diet.
Which actions
require
intervention by the
nurse? Select all
that apply.
1. The UAP adds
milk to mashed
potatoes to make
them thinner.
2. The UAP
encourages the
client to
occasionally turn
the head to the
left
