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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason: This is correct because a pulmonary artery catheter is a device that measures the pressures and ﬂows in the heart and lungs, such as the pulmonary artery pressure, the pulmonary artery wedge pressure, the cardiac output, and the mixed venous oxygen saturation. These parameters reﬂect the hemodynamic status of the client, which is the balance between the cardiac output and the systemic vascular resistance.

Choice B Reason: This is incorrect because a pulmonary artery catheter does not measure spinal cord perfusion, which is the blood ﬂow to the spinal cord. Spinal cord perfusion can be aﬀected by spinal cord injury, spinal anesthesia, or spinal surgery.

Choice C Reason: This is incorrect because a pulmonary artery catheter does not measure renal function, which is the ability of the kidneys to filter waste products and maintain ﬂuid and electrolyte balance. Renal function can be assessed by urine output, blood urea nitrogen, creatinine, and glomerular filtration rate.

Choice D Reason: This is incorrect because a pulmonary artery catheter does not measure intracranial pressure, which is the pressure inside the skull. Intracranial pressure can be increased by brain injury, stroke, tumor, infection, or hydrocephalus.

A. pH 7.49, HCO3 24, PaCO2 30 B. pH 7.26, HCO3 24, PaCO2 46 C. pH 7.26, HCO3 14, PaCO2 30 D. pH 7.49, HCO3 30, PaCO2 40

Correct Answer is C

Explanation

Choice A Reason: This choice is incorrect because it indicates respiratory alkalosis, not AKI. Respiratory alkalosis is a condition in which the lungs eliminate too much carbon dioxide (CO2) from the blood, resulting in a low level of CO2 (PaCO2) and a high level of pH. A normal PaCO2 range is 35 to 45 mm Hg, and a normal pH range is 7.35 to 7.45, so a value of 30 mm Hg and 7.49 indicate respiratory alkalosis.

Choice B Reason: This choice is incorrect because it indicates respiratory acidosis, not AKI. Respiratory acidosis is a condition in which the lungs cannot eliminate enough CO2 from the blood, resulting in a high level of CO2 (PaCO2) and a low level of pH. A value of 46 mm Hg and 7.26 indicate respiratory acidosis.

Choice C Reason: This choice is correct because it indicates metabolic acidosis, which is a common complication of AKI. Metabolic acidosis is a condition in which the body produces too much acid or loses too much base, resulting in a low level of bicarbonate (HCO3) and a low level of pH. A normal HCO3 range is 22 to 26 mEq/L, so a value of 14 mEq/L indicates metabolic acidosis. The low PaCO2 value (30 mm Hg) is due to the respiratory compensation mechanism that tries to restore the acid-base balance by increasing the ventilation and eliminating more CO2.

Choice D Reason: This choice is incorrect because it indicates metabolic alkalosis, not AKI. Metabolic alkalosis is a condition in which the body loses too much acid or gains too much base, resulting in a high level of bicarbonate (HCO3) and a high level of pH. A value of 30 mEq/L and 7.49 indicate metabolic alkalosis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

Correct Answer is A

Explanation

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

Correct Answer is C

Explanation

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?

A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?

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?

A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse in the emergency department is caring for a client who has 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?

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?