A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

Prepare the client for an MRl of the brain.

Administer mannitol IV bolus to the client.

Determine the client's Glasgow Coma Scale score.

D insert an indwelling urinary catheter for the client.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Determine the client’s Glasgow Coma Scale score. This is because the Glasgow Coma Scale (GCS) is a tool to assess the level of consciousness and neurological status of a client who has a closed head injury. The GCS score can help guide the priority of interventions and the need for further diagnostic tests.

Choice A is wrong because an MRI of the brain is not the first action to take for a client who has a closed head injury. An MRI may be indicated later to evaluate the extent of brain damage, but it is not an emergency procedure.

Choice B is wrong because mannitol IV bolus is a medication that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue. However, mannitol should not be administered before confirming the presence and degree of increased ICP, which can be done by measuring the GCS score and other vital signs.

Choice D is wrong because inserting an indwelling urinary catheter for the client is not the first action to take for a client who has a closed head injury. A urinary catheter may be needed to monitor fluid balance and renal function, but it is not an urgent intervention.

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Correct Answer is D

Explanation

The correct first action for the charge nurse to take in response to an increase in facility-acquired catheter infections is toidentify possible precipitating factors related to the infections. This is because understanding the root cause of the problem is crucial before implementing any changes or interventions. By identifying the factors contributing to the increase in infections, the nurse can then develop targeted strategies to address these specific issues.

Now, let’s discuss why the other options are not the first actions to take:

Schedule nursing staff training for infection control procedures: While training is important, it should be based on identified needs. Without first understanding the precipitating factors of the increased infections, the training may not address the actual issues at hand.
Meet with providers to discuss measures to decrease the infections: This could be a subsequent step after identifying the precipitating factors. Meeting with providers without concrete data or understanding of the problem may lead to ineffective solutions.
Revise the current policy for catheter care: Policy revision should be based on evidence and identified needs. It would be premature to revise policies without first understanding what factors are contributing to the increase in infections.

In summary, the first step in addressing a problem is always to understand its causes. Only then can effective solutions be developed and implemented.

A. I can lift objects that are less than 10 pounds B. I can resume activities, such as sewing C. I can go jogging after 2 weeks D. I should bend at the waist when putting on my shoes

Correct Answer is A

Explanation

The correct answer is A. I can lift objects that are less than 10 pounds.

Here's a breakdown of why the other options are incorrect:

B. I can resume activities, such as sewing. - Sewing requires fine motor skills and close eye work, which can increase intraocular pressure and potentially worsen the detached retina.
C. I can go jogging after 2 weeks. - Strenuous activities like jogging can increase blood pressure and strain the eye, potentially leading to another retinal detachment.
D. I should bend at the waist when putting on my shoes. - Bending at the waist increases intraocular pressure and can strain the eye. It's recommended to sit down or use a stool to put on shoes.

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A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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