A client is admitted to the intensive care unit (ICU) after a colon resection with the formation of a loop colostomy. The nurse determines the client's abdominal dressing is clean and dry. Vital signs are temperature 100° F (37.8° C) orally, heart rate 132 beats/minute, blood pressure 88/65 mm Hg, and urine output 10 mL/hour. Which intervention should the nurse implement?

Place a cooling blanket on the client.

Administer an antipyretic agent.

Give a 500 mL IV fluid bolus challenge.

Titrate IV vasopressor for systolic less than 80.

Answer and Explanation

The Correct Answer is C

A. Place a cooling blanket on the client. A temperature of 100°F (37.8°C) is only mildly elevated and does not require active cooling. The priority concern is hemodynamic instability due to hypovolemia, not fever management. Cooling blankets are typically used for high fevers (≥ 102°F or 38.9°C).
B. Administer an antipyretic agent. While fever may indicate postoperative infection or inflammatory response, the client’s most critical issue is hypotension and low urine output, suggesting hypovolemia or early shock. Treating the underlying cause (fluid loss) is more urgent than giving an antipyretic.
C. Give a 500 mL IV fluid bolus challenge. The client has tachycardia (132 bpm), hypotension (88/65 mm Hg), and oliguria (10 mL/hour), all of which suggest hypovolemic shock, a common postoperative complication. A fluid bolus (typically 500–1000 mL of isotonic crystalloid such as normal saline or lactated Ringer’s) is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.
D. Titrate IV vasopressor for systolic less than 80. Vasopressors (e.g., norepinephrine) are not the first-line treatment for hypovolemic shock. Fluids should be administered first to correct volume loss before considering vasopressors. If hypotension persists despite adequate fluid resuscitation, vasopressors may be initiated.

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Correct Answer is D

Explanation

A. Prepare to give phenytoin IV as prescribed. Phenytoin is used for seizure prophylaxis in clients with moderate to severe head injuries (GCS ≤ 8–10). A GCS score of 14 indicates mild head injury, and prophylactic anticonvulsants may not be necessary unless ordered for specific risk factors.
B. Perform a substernal rub to evoke a response to pain. A substernal rub (painful stimulus) is used to assess response in unconscious or unresponsive clients (GCS ≤ 8). With a GCS of 14, the client is alert or nearly fully conscious, making a painful stimulus unnecessary and inappropriate.
C. Promptly notify the healthcare provider (HCP) of the GCS score. A GCS of 14 is not a critical or emergency finding, as it indicates mild neurological impairment. While the HCP should be updated on significant changes, routine monitoring is sufficient unless deterioration occurs.
D. Continue monitoring the client's GCS score every 2 hours. Frequent neurological assessments are crucial in head injury management to detect worsening conditions like increasing intracranial pressure (ICP) or cerebral edema. Monitoring the GCS every 2 hours ensures timely intervention if the client’s condition changes.

A. Allow the family to touch and talk to the client. B. Reassess the client's vascular access. C. Assess neurological vital signs every 15 minutes. D. Administer ophthalmic ointment. E. Apply soft bilateral wrist restraints for transport.

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

Explanation

A. Allow the family to touch and talk to the client. Family presence can provide emotional support for both the client and loved ones. Even though the client is sedated and has a low GCS, familiar voices and touch may reduce stress and anxiety. Allowing family interaction fosters comfort and connection during a critical time.
B. Reassess the client's vascular access. Maintaining secure and functional vascular access is essential for administering fluids, medications, and emergency interventions. Before transport, the nurse should confirm IV patency, ensure secure connections, and assess for signs of infiltration or malfunction. Trauma patients may require additional or larger bore IV access for fluid resuscitation or transfusion.
C. Assess neurological vital signs every 15 minutes. Frequent neurological assessments are crucial in head trauma patients with a low GCS to monitor for signs of worsening intracranial pressure, cerebral edema, or herniation. Changes in pupil response, motor function, or vital signs may indicate neurological deterioration requiring urgent intervention. Monitoring trends over time is necessary for early detection of complications.
D. Administer ophthalmic ointment. Clients with a low GCS often have impaired blinking, placing them at risk for corneal abrasions and dryness. Applying ophthalmic lubricant or artificial tears protects the cornea from injury and promotes eye health. Preventing exposure keratitis is essential in unconscious or sedated clients to avoid long-term ocular damage.
E. Apply soft bilateral wrist restraints for transport. Restraints are unnecessary because the client is sedated, intubated, and has a GCS of 6, meaning they cannot attempt self-extubation or interfere with care. Restraints should only be used if the client demonstrates a risk of harm. Standard transport protocols prioritize sedation and safety measures over restraints unless specifically required.

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Naxlex Comprehensive Predictor Exams

The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?

Correct Answer is D

Explanation

An adult with head and facial injuries from a motor vehicle collision is fully immobilized and has a Glasgow coma score of 6. The client is intubated, sedated, and is being prepared for transfer to a regional trauma center. Which intervention(s) should the nurse implement? Select all that apply.

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

Explanation

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