A client is admitted to the intensive care unit (ICU) with a traumatic brain injury. Which invasive procedure should the nurse anticipate preparing the client to undergo?

Tracheostomy placement

Central line insertion

Nasogastric tube (NGT) insertion

Pacemaker placement

Answer and Explanation

The Correct Answer is C

Choice A reason: Tracheostomy placement is for prolonged airway management, not immediate in traumatic brain injury (TBI). NGT insertion addresses acute needs like gastric decompression or feeding, as TBI may impair swallowing, making this procedure less urgent than managing intracranial complications.

Choice B reason: Central line insertion provides vascular access but is not specific to TBI. NGT insertion prevents aspiration or manages gastric contents, critical in TBI with altered consciousness, making central lines secondary, as they address fluid or medication needs, not TBI-specific issues.

Choice C reason: NGT insertion is anticipated, as traumatic brain injury often impairs swallowing or consciousness, increasing aspiration risk. The tube decompresses the stomach or delivers nutrition, preventing complications like pneumonia, making it a priority procedure to support TBI management and patient stability.

Choice D reason: Pacemaker placement addresses cardiac arrhythmias, unrelated to traumatic brain injury. NGT insertion manages gastric or nutritional needs in TBI, where neurological deficits are primary, making pacemakers irrelevant, as TBI does not typically involve acute cardiac conduction issues.

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

Explanation

Choice A reason: Contact precautions prevent MRSA spread, as it transmits via direct contact or contaminated surfaces. Isolation with gowns and gloves reduces nosocomial infection risk, critical for protecting staff and patients, making this a key intervention in the plan of care for suspected MRSA.

Choice B reason: Administering vancomycin is essential, as it treats MRSA, a resistant bacterium requiring specific antibiotics. Vancomycin targets cell wall synthesis, effective against MRSA, and prompt administration prevents systemic spread, making it a critical intervention for confirmed or suspected infections.

Choice C reason: Obtaining a wound culture confirms MRSA diagnosis by identifying the pathogen and its antibiotic sensitivity. This guides targeted therapy, ensuring effective treatment and preventing resistance, making it a vital step in managing suspected MRSA infections in the care plan.

Choice D reason: Monitoring white blood cell count tracks infection severity, as leukocytosis indicates MRSA’s systemic inflammatory response. This helps assess treatment response and complications, making it an important intervention to evaluate the client’s condition and guide ongoing management of the infection.

Choice E reason: Ensuring hand hygiene compliance prevents MRSA transmission, a highly contagious pathogen spread via contact. Rigorous handwashing reduces cross-contamination, protecting the client, staff, and others, making it an essential intervention in the care plan for infection control.

A. Elevate both lower extremities B. Administer a PRN diuretic as prescribed C. Evaluate edema of the lower extremities D. Assess distal pulses with a Doppler device

Correct Answer is D

Explanation

Choice A reason: Elevating extremities reduces edema but does not address absent pulses, indicating possible arterial occlusion post-AAA repair. Doppler assessment confirms pulse status, identifying critical ischemia, and elevation is secondary, as it does not diagnose the underlying vascular compromise requiring urgent intervention.

Choice B reason: Administering a diuretic treats edema but ignores absent pulses, a sign of arterial compromise post-AAA repair. Doppler assessment identifies ischemia, and diuretics may worsen hypovolemia, risking graft failure, making this action less urgent than confirming vascular patency.

Choice C reason: Evaluating edema provides data but does not prioritize absent pulses, suggesting arterial occlusion post-AAA repair. Doppler assessment directly confirms pulse status, guiding urgent vascular intervention, and edema evaluation is secondary, as pulses indicate a more immediate threat to limb viability.

Choice D reason: Assessing distal pulses with Doppler is critical first, as absent pulses post-AAA repair suggest graft thrombosis or arterial occlusion, risking limb ischemia. Doppler confirms pulse presence, guiding urgent surgical consultation, making it the priority to prevent irreversible tissue damage or amputation.

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A client is admitted to the intensive care unit (ICU) with a traumatic brain injury. Which invasive procedure should the nurse anticipate preparing the client to undergo?

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Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is D

Explanation

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