Muscular dystrophy

A young adult with muscular dystrophy is transferred to the intensive care unit after falling while walking into the bathroom. On admission, the client is complaining of severe headaches. which intervention should the nurse implement first?

a.Give an intravenous

b.Insert indwelling urinary catheter

c. Administer an intravenous antiemetic

d.Complete neurological assessment

6. The nurse is evaluating the pulmonary wedge pressure for a client who has a small bowel resection for a necrotic bowel. The nurse recognizes a dampen pulmonary artery waveform. Which action should the nurse implement?

a.Measure the amount of exposed catheter

b.Advance the PA catheter until the dicrotic notch reappears

c. Inflate and lock the balloon immediately

d.Troubleshoot for causes of low pressure in the system

8. A client who is being mechanically ventilated had an oxygen saturation of 98% and is scheduled for bronchoscopy in the morning. Propofol is infusing at 10mcg/kg/min and normal saline at 100 ml/hour. The clients tube feeding is at 20mL/hr via orogastric tube. Which intervention should the nurse implement prior to the bronchoscopy?

a.Adjust the mechanical ventilator to provide client with 100% oxygen

b.Turn off the sedation and have the client sign bronchoscopy consent

c. Stop tube feeding at midnight and keep the head of the bed elevated

d.Discontinue the orogastric tube and insert nasogastric tube

12. A client who experienced multiple traumatic injuries begins to ooze blood from an injection site. Which additional finding should the nurse identify that supports an early indication of disseminated intravascular coagulation?

a.Edema of the extremities

b.Negative D-dimer test

c. Bleeding from oral mucosa

d.Shorter clotting times

15. The nurse assesses the telemetry monitor of a client who is 24 hours post-operative for permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in ECG lead 2. Which intervention should the nurse implement?

a.Document that the client is experiencing a paced rhythem

b.Reposition the ECG leads and obtain another recording

c. Assess the client for symptoms of decrease cardiac output

d.Notify the healthcare provider of the telemetry record

16. A client is admitted to the intensive care unit with aspiration pneumonia following an intentional acetaminophen overdose. The client is obtunded and mechanically ventilated with 50% FiO2. Serum laboratory findings include BUN 95, creatinine2.3, and ALT. Vital signs are temperature 89.6F, HR 54 bpm, and BP60/40. Which intervention should the nurse implement first?

a.Notify the poison control center

b.Apply continuous warming blanket

c. Initiate N-acestylcysteine infusion

d.Rapidly infuse IV of normal saline

Note: Please give short explanation/rational why the answer is correct