A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Slow the rate to 50 mL/hr.

Slow the rate to 20 mL/hr.

Continue the rate at 125 mL/hr.

Increase the rate to 250 mL/hr.

Answer and Explanation

The Correct Answer is C

The correct answer is: C. Continue the rate at 125 mL/hr.
Choice A: Slow the rate to 50 mL/hr
Slowing the IV fluid rate to 50 mL/hr is not appropriate for a patient with a head injury. Adequate fluid management is crucial to maintain cerebral perfusion pressure and prevent secondary brain injury. Reducing the rate to 50 mL/hr could lead to hypovolemia, which might decrease cerebral perfusion and worsen the patient’s condition.
Choice B: Slow the rate to 20 mL/hr
Slowing the IV fluid rate to 20 mL/hr is even less appropriate. Such a low rate would likely result in significant hypovolemia, severely compromising cerebral perfusion pressure. This could exacerbate the patient’s head injury by reducing the blood flow to the brain, leading to further damage.
Choice C: Continue the rate at 125 mL/hr
Continuing the rate at 125 mL/hr is appropriate. This rate helps maintain euvolemia, which is essential for ensuring adequate cerebral perfusion pressure in patients with head injuries. Maintaining a stable fluid rate helps prevent both hypovolemia and hypervolemia, both of which can negatively impact intracranial pressure and cerebral perfusion.
Choice D: Increase the rate to 250 mL/hr
Increasing the IV fluid rate to 250 mL/hr is not recommended. Overhydration can lead to increased intracranial pressure, which can be detrimental to a patient with a head injury. Excessive fluid administration can cause cerebral edema, worsening the patient’s condition.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect. Anginal pain usually lasts less than 20 min and subsides with rest or medication. Pain that lasts longer than 20 min may indicate a myocardial infarction.

Choice B Reason: This is incorrect. Anginal pain usually responds to rest and organic nitrates, such as nitroglycerin. Pain that does not improve with these measures may indicate unstable angina or a myocardial infarction.

Choice C Reason: This is incorrect. Anginal pain is not aﬀected by the position of the client. Pain that is relieved by sitting up may indicate pericarditis or pleurisy.

Choice D Reason: This is correct. Anginal pain is caused by a temporary imbalance between the oxygen demand and supply of the myocardium. Factors that increase the oxygen demand, such as exertion, anxiety, cold, or heavy meals, can trigger anginal pain.

A. Heart rate 180/min B. Motled skin C. Hypokalemia D. Blood pressure 115/68 mm Hg

Correct Answer is D

Explanation

The correct answer is D. Blood pressure 115/68 mm Hg.

Choice A reason: Heart rate 180/min is incorrect because, although an increased heart rate is a compensatory mechanism, a rate of 180/min is excessively high and suggests a more severe stage of shock or other cardiac issues.

Choice B reason: Mottled skin is incorrect as it indicates poor perfusion seen in decompensated shock, where organ dysfunction begins to manifest, not in the compensatory stage.

Choice C reason: Hypokalemia, or low potassium levels, is incorrect because electrolyte imbalances are not typically a finding in the compensatory stage of shock. Normal potassium levels range from 3.5 to 5.0 mEq/L.

Choice D reason: Blood pressure 115/68 mm Hg is correct because it falls within the normal blood pressure range, which the body strives to maintain during the compensatory stage of shock through various mechanisms.

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A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Nursing Test Bank

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