A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse?

Blood pressure 110/72 mm Hg

Intracranial pressure (ICP) 25 mm Hg

PaC02 35 mm Hg

Pulse oximetry 96%

Answer and Explanation

The Correct Answer is B

A. Blood pressure 110/72 mm Hg: A blood pressure of 110/72 mm Hg is within the normal range and does not require intervention. Maintaining a stable blood pressure is essential after a craniotomy, and this reading indicates no immediate concerns.

B. Intracranial pressure (ICP) 25 mm Hg: An ICP of 25 mm Hg is above the normal range (typically 5-15 mm Hg). Elevated ICP can lead to brain herniation and other severe complications. The nurse should notify the healthcare provider immediately and take measures to reduce ICP, such as positioning and administering medications if needed.

C. PaCO2 35 mm Hg: A PaCO2 of 35 mm Hg is within the normal range (35-45 mm Hg). The normal level of carbon dioxide is important for maintaining appropriate cerebral perfusion pressure, and this value does not indicate a problem.

D. Pulse oximetry 96%: A pulse oximetry reading of 96% is within the normal range (95-100%) and indicates adequate oxygenation. No immediate intervention is needed unless the value drops significantly below this level.

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Correct Answer is A

Explanation

A. Inspect the mouth for signs of inhalation injuries: The priority action for a client with burns, especially facial burns is to assess for potential inhalation injuries. Inhalation of hot gases or smoke can cause damage to the airways, leading to swelling, obstruction, and respiratory distress.

B. Administer intravenous pain medication: Pain management is important, but it is not the immediate priority. Ensuring the client’s airway is protected and that there are no life-threatening respiratory complications takes precedence over pain relief in the early stages of burn care.

C. Insert an indwelling urinary catheter: Inserting a urinary catheter is typically done for monitoring urine output in burn patients, especially if there is concern for fluid resuscitation needs. However, it is not the priority. Assessing for respiratory injury should come first.

D. Draw blood for a complete blood cell (CBC) count: While a CBC can provide useful information, such as signs of infection or anemia, it is not the priority action. The immediate priority is ensuring the airway is safe and free of inhalation injury, as respiratory compromise can lead to rapid deterioration.

A. Sinus Bradycardia B. Sinus Tachycardia C. Supraventricular Tachycardia D. Normal Sinus Rhythm (NSR)

Correct Answer is C

Explanation

A. Sinus Bradycardia: Sinus bradycardia is characterized by a heart rate below 60 beats per minute, which is clearly not the case in this EKG strip. The observed rate of 150 bpm is well above the bradycardic range.

B. Sinus Tachycardia: Although this is a fast rhythm (over 100 bpm), sinus tachycardia typically has visible and upright P waves preceding each QRS complex. In this strip, the P waves are not clearly visible, suggesting a non-sinus origin.

C. Supraventricular Tachycardia (SVT): SVT is a rapid, regular rhythm originating above the ventricles, often with no clearly identifiable P waves and narrow QRS complexes. The rate appears very fast and regular—typical of SVT.

D. Normal Sinus Rhythm (NSR): Normal sinus rhythm is characterized by a regular heart rate between 60 and 100 beats per minute, with normal P waves preceding each QRS. The heart rate of 150 bpm in the given strip falls outside the normal range for NSR.

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A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse?

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