A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

Observe for cerebrospinal ﬂuid (CSF) leaks from the evacuation site.

Check the oximeter.

Assess for an increase in temperature.

Monitor for manifestations of increased intracranial pressure.

Answer and Explanation

The Correct Answer is B

Choice A Reason: Observing for cerebrospinal ﬂuid (CSF) leaks from the evacuation site is important, but not the first action that the nurse should take. CSF leaks can indicate a breach in the dura mater, which can increase the risk of infection and meningitis. The nurse should inspect the dressing and the nose and ears for any clear or bloody drainage, and report any findings to the provider. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice B Reason: The first action the nurse should take when caring for a client post-evacuation of a subdural hematoma is to check the oximeter to ensure adequate oxygenation. Maintaining proper oxygenation is a priority because hypoxia and hypercapnia can lead to cerebral vasodilation, increasing intracranial pressure (ICP) and worsening neurological outcomes. Key Concept: Always prioritize Airway, Breathing, and Circulation (ABCs) when determining the most immediate nursing intervention.

Choice C Reason: Assessing for an increase in temperature is another important action, but not the first one that the nurse should take. An increase in temperature can indicate an infection, inﬂammation, or damage to the hypothalamus, which can aﬀect the thermoregulation of the body. The nurse should monitor the temperature and administer antipyretics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice D Reason:This is crucial, but oxygenation status should be checked first since low oxygen levels can worsen ICP.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can cause ﬂuid overload and pulmonary edema in a client who has burns.

Choice B Reason: This is incorrect because dextrose 5% in water is a hypotonic solution that can cause ﬂuid shifts from the intravascular space to the interstitial space, resulting in hypovolemia and hypotension in a client who has burns.

Choice C Reason: This is incorrect because 0.9% sodium chloride is an isotonic solution that can cause hypernatremia and hyperchloremia in a client who has burns, as the ﬂuid loss from burns is greater than the sodium loss.

Choice D Reason: This is correct because lactated Ringer's is an isotonic solution that contains electrolytes similar to plasma, such as sodium, potassium, calcium, and chloride. It also contains lactate, which is converted to bicarbonate in the liver and helps correct the metabolic acidosis that occurs in a client who has burns.

A. Drainage of clear ﬂuid from the ears B. Alternating periods of alertness and unconsciousness C. Narrowing pulse pressure D. Extensive bruising in the mastoid area

Correct Answer is B

Explanation

Choice A: Drainage of clear ﬂuid from the ears is not an expected finding for a client who has an epidural hematoma, but rather a sign of a basilar skull fracture, which is a diﬀerent type of head injury. The clear ﬂuid is cerebrospinal ﬂuid (CSF), which leaks from the brain through the fractured skull.

Choice B: Alternating periods of alertness and unconsciousness is an expected finding for a client who has an epidural hematoma, because it indicates a rapid increase in intracranial pressure (ICP) due to bleeding between the dura mater and the skull. The client may have a brief loss of consciousness at the time of injury, followed by a lucid interval, and then a rapid deterioration of mental status.

Choice C: Narrowing pulse pressure is not an expected finding for a client who has an epidural hematoma, but rather a sign of increased ICP due to any cause. Pulse pressure is the diﬀerence between systolic and diastolic blood pressure. As ICP rises, it compresses the brainstem and causes bradycardia and hypertension, resulting in a decreased pulse pressure.

Choice D: Extensive bruising in the mastoid area is not an expected finding for a client who has an epidural hematoma, but rather a sign of a basilar skull fracture, which is a diﬀerent type of head injury. The bruising is also known as Batle's sign, and it occurs due to blood pooling behind the ear.

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A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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