A 45-year-old male patient present to the emergency department with a severe head injury following a car accident. His Glasgow Coma Scale (GCS) score is 8, and he shows signs of increased intracranial pressure (ICP). Which of the following interventions should be prioritized to manage his ICP?

Administering mannitol intravenously

Encouraging the patient to hyperventilate

Administering a high-dose corticosteroid

Performing a lumbar puncture immediately

Answer and Explanation

The Correct Answer is A

A. Administering mannitol intravenously: Mannitol is an osmotic diuretic that helps reduce ICP by drawing fluid out of brain tissue and decreasing cerebral edema, making it a priority intervention.

B. Encouraging the patient to hyperventilate: Controlled hyperventilation may reduce ICP temporarily by lowering CO₂ levels and causing cerebral vasoconstriction. However, it should only be done cautiously under close monitoring, and other ICP management techniques like mannitol administration take priority.

C. Administering a high-dose corticosteroid: Corticosteroids are generally ineffective for reducing ICP in traumatic brain injury and are typically not recommended in this scenario.

D. Performing a lumbar puncture immediately: Lumbar puncture is contraindicated in cases of increased ICP because it may lead to brain herniation due to the sudden release of pressure.

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Correct Answer is A

Explanation

A. Reposition the client at least every two hours. Regular repositioning reduces prolonged pressure on specific areas of the body, which helps prevent the formation of pressure injuries.

B. Encourage the client to limit fluid intake. Adequate hydration is important for skin integrity. Limiting fluid intake could lead to dehydration, increasing the risk for skin breakdown.

C. Use a donut-shaped cushion under the client's hips. Donut-shaped cushions can actually increase pressure around the edges of the cushion and restrict blood flow, which could worsen pressure injury risk.

D. Apply a heating pad to the client's back every four hours. Heat can cause skin damage and may increase the risk of burns. Temperature regulation is important, but heating pads are not recommended for pressure injury prevention.

A. Ensure that the client's urine output is at least 1ml/kg/hr B. Ensure potassium infusion is prepared with 5% dextrose solution C. Educate client regarding high-potassium food sources D. Repeat blood serum potassium E. Cardiac monitoring during infusion

Correct Answer is ["A","C","D","E"]

Explanation

A. Ensure that the client's urine output is at least 1 ml/kg/hr. Adequate urine output is essential before administering IV potassium to ensure the kidneys are functioning properly and can handle the increased potassium load, preventing hyperkalemia.

B. Ensure potassium infusion is prepared with 5% dextrose solution. While IV potassium can be mixed with normal saline or dextrose solutions, the specific diluent will depend on the clinical scenario. This isn't necessarily a standard requirement, so it may not be appropriate for all situations.

C. Educate the client regarding high-potassium foods. Education on high-potassium foods helps the client maintain potassium levels after treatment, reducing the need for future supplementation.

D. Repeat blood serum potassium levels. Rechecking potassium levels ensures the patient reaches a safe and therapeutic range and helps monitor for signs of overcorrection or continued hypokalemia.

E. Cardiac monitoring during infusion. Cardiac monitoring is critical, as hypokalemia and potassium replacement can affect heart rhythm and lead to arrhythmias.

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A 45-year-old male patient present to the emergency department with a severe head injury following a car accident. His Glasgow Coma Scale (GCS) score is 8, and he shows signs of increased intracranial pressure (ICP). Which of the following interventions should be prioritized to manage his ICP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the care plan to help prevent the development of pressure Injuries?

Correct Answer is A

Explanation

A nurse is assisting with preparations for administering intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L. Which of the following actions should the nurse plan to include? (Select All that Apply.)

Correct Answer is ["A","C","D","E"]

Explanation

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