NGN EXAM RETAKE 2 ATI RN MEDICAL SURGICAL MED SURG A WITH QUESTIONS AND ANSWERS A nurse is caring for a client who has a closed head injury andhas an intraventricular catheter placed. Which of the followingfindings indicates that the client is experie

NGN EXAM RETAKE 2 ATI RN MEDICAL SURGICAL MED S URG A WITH QUESTIONS AND ANSWERS A nurse is caring for a client who has a closed head injury andhas an intraventricular catheter placed. Which of the followingfindings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.) A. Flat jugular veins B. A Glasgow Coma Scale score of 15C. Sleepiness exhibited by the client D. Widening pulse pressure E. Decerebrate posturing - CORRECT ANSWER C, D, E Flat jugular veins is incorrect. With increased ICP, the jugularveins are typically distended. A Glasgow Coma Scale score of 15 is incorrect. A Glasgow ComaScale score of 15 indicates neurological functioning within the expected reference range for eye opening, motor, and verbal response. Sleepiness exhibited by the client is correct. Sleepiness ordifficulty arousing the client from sleep is an indication of increased ICP. Widening pulse pressure is correct. A widening pulse pressure(increase in systolic with concurrent decrease in diastolic bloodpressure) is an indication of increased ICP. Decerebrate posturing is correct. Both decerebrate anddecorticate posturing indicate increased ICP. A nurse is preparing a client who has supraventricular tachycardiafor elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? A. EnoxaparinB. Metformin C. Diazepam D. Digoxin - CORRECT ANSWER D. Digoxin Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation afterthe synchronized countershock of cardioversion. A nurse is assessing a client who has acute cholecystitis. Whichof the following findings is the nurse's priority? A. Anorexia B. Abdominal pain radiating to the right shoulderC. Tachycardia D. Rebound abdominal tenderness - CORRECT ANSWER C. Tachycardia The nurse should wear a lead apron when providing direct care toprovide protection from the radiation source and not turn their back toward the client, because the apron only shields the front ofthe body. The nurse should also wear a dosimeter film badge to measure radiation exposure. A nurse is preparing to administer a unit of packed RBCs to aclient. Which of the following actions should the nurse take? A. Remain with the client for the first 15 min of the infusion B. Prime the blood administration IV tubing with lactated Ringer'ssolutio