A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician
diagnoses a closed head injury with suspected
... [Show More] subdural hematoma. Although complaining of a severe
headache, the client is alert and answers questions appropriately. The nurse should question which of
the following orders?
1. "Promethazine (Phenergan) 25 mg IM 3 h."
2. "Morphine sulfate 10 mg IM q3 4h."
3. "Docusate sodium (Colace) 50 mg PO bid."
4. "Ranitidine (Zantac) 50 mg IVPB q12h."
(1) H1 receptor blocker, used as an antiemetic
(2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury
because it masks signs of increased intracranial pressure
(3) stool softener, used for an immobilized patient
(4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers
The nurse returns to the desk and finds four phone messages to return. Which of the following messages
should the nurse return FIRST?
1. A woman in the first trimester of pregnancy complains of heartburn.
2. A man complains of heartburn that radiates to the jaw.
3. A woman complains of hot flashes and difficulty sleeping.
4. A boy complains of knee pain after playing basketball.
(1) caused by reflux of gastric contents into esophagus, treatment is small, frequent meals, don't
consume fluids with food, don't wear tight clothing
(2) correct—indicates chest pain, needs to seek medical attention immediately
(3) caused by menopause, treat with hormone replacement therapy (HRT)
(4) should treat with rest and ice
A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The
nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in
which of the following positions?
1. Head of bed elevated 30-45°.
2. Head of bed elevated 60-90°.
3. Side-lying with head elevated 15°.
4. Lying flat with head turned to the left side.
(1) head of bed not elevated enough
(2) correct—facilitates swallowing and movement of tube through gastrointestinal tract
(3) not the best position
(4) not the best position
The nurse monitors the fluid status of an older patient receiving IV fluids following surg [Show Less]