A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Respiratory status

Temperature

Intracranial pressure

Serum electrolytes

Answer and Explanation

The Correct Answer is A

The correct answer is a. Respiratory status.

Choice A: Respiratory Status

Reason: After the evacuation of a subdural hematoma, monitoring the respiratory status is crucial. This is because changes in respiratory patterns can indicate increased intracranial pressure (ICP) or brainstem compression, which are life-threatening conditions. Ensuring that the airway is clear and that the patient is breathing adequately is the top priority. Normal respiratory rate for adults is 12-20 breaths per minute.

Choice B: Temperature

Reason: While monitoring temperature is important to detect infections or other complications, it is not the immediate priority in the acute postoperative period following a subdural hematoma evacuation. Fever can indicate infection, but it is less likely to cause immediate life-threatening complications compared to respiratory issues.

Choice C: Intracranial Pressure

Reason: Monitoring intracranial pressure (ICP) is very important in patients with brain injuries. Normal ICP ranges from 5-15 mmHg. However, changes in respiratory status can be an early indicator of increased ICP. Therefore, while ICP monitoring is critical, ensuring the patient’s respiratory status is stable takes precedence.

Choice D: Serum Electrolytes

Reason: Serum electrolytes are important to monitor for overall metabolic stability and to detect imbalances that could affect neurological function. Normal ranges for key electrolytes are: Sodium (135-145 mEq/L), Potassium (3.5-4.5 mEq/L), and Chloride (80-100 mEq/L). However, these are not the immediate priority in the acute phase following surgery compared to respiratory status.

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Correct Answer is A

Explanation

Choice A Reason: This choice is correct because slow, steady bubbling in the suction control chamber indicates that the suction is working properly and maintaining a negative pressure in the pleural space. The nurse should continue to monitor the client's respiratory status, such as breath sounds, oxygen saturation, and respiratory rate, to assess the eﬀectiveness of the chest drainage system.

Choice B Reason: This choice is incorrect because checking the suction control outlet on the wall is not necessary unless there is no bubbling in the suction control chamber, which would indicate a problem with the suction source or setting. The nurse should ensure that the suction control outlet is set at the prescribed level, usually between 10 and 20 cm H2O.

Choice C Reason: This choice is incorrect because clamping the chest tube is not indicated unless there is a leak in the system or the chest drainage unit needs to be changed. Clamping the chest tube may cause a buildup of air or ﬂuid in the pleural space, which can lead to tension pneumothorax or pleural eﬀusion.

Choice D Reason: This choice is incorrect because checking the tubing connections for leaks is not necessary unless there is continuous bubbling in the water seal chamber, which would indicate an air leak in the system. The nurse should ensure that all tubing connections are tight and secure, and tape any loose connections.

A. Clamp the client's chest tube. B. Increase the client's wall suction. C. Reposition the client. D. Strip the client's chest tube.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because clamping the client's chest tube can cause a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.

Choice B Reason: This is incorrect because increasing the client's wall suction can cause excessive negative pressure in the pleural space, which can damage the lung tissue and impair ventilation.

Choice C Reason: This is correct because repositioning the client can help relieve chest burning, which may be caused by irritation of the intercostal nerves by the chest tube or by air trapping in the pleural space.

Choice D Reason: This is incorrect because stripping the client's chest tube can create high negative pressure in the pleural space, which can damage the lung tissue and impair ventilation.

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A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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Here is the edited text: A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?