A nurse is caring for a client who has a closed-head injury with elevated ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP?
Elevate the client's head on two pillows.
Keep the client well hydrated.
Decrease the noise level in the client's room.
Suction the endotracheal tube frequently.
The Correct Answer is C
Choice A Reason:
Elevating the client's head on two pillows can help reduce ICP by promoting venous drainage from the brain. However, it is important to ensure that the head is not elevated too high, as this can impede venous return and potentially increase ICP. The recommended elevation is typically 30 degrees. While this intervention is beneficial, it is not the most critical action compared to reducing environmental stimuli.
Choice B Reason:
Keeping the client well hydrated is essential for overall health, but excessive hydration can increase ICP by increasing the volume of cerebrospinal fluid and blood within the cranial vault. Fluid management must be carefully monitored to avoid exacerbating ICP. Therefore, while hydration is important, it must be balanced and not excessive.
Choice C Reason:
Decreasing the noise level in the client's room is crucial for minimizing external stimuli that can increase ICP. Noise and other environmental stressors can lead to increased agitation and stress, which in turn can elevate ICP. Creating a calm and quiet environment helps in maintaining a stable ICP and is a non-invasive, easily implementable intervention.
Choice D Reason:
Frequent suctioning of the endotracheal tube can cause transient increases in ICP due to the stimulation and potential for coughing. While suctioning is necessary to maintain airway patency, it should be performed judiciously and only when clinically indicated. Over-suctioning can lead to spikes in ICP and should be avoided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Administer intravenous pain medication
Administering intravenous pain medication is crucial for managing pain in burn patients. Pain management is essential to ensure the patient's comfort and to prevent complications such as shock. However, while important, it is not the immediate priority in this scenario. The primary concern should be assessing and securing the airway, especially given the location of the burns on the face and chest, which could indicate potential inhalation injuries.
Choice B: Draw blood for a complete blood cell (CBC) count
Drawing blood for a CBC count is important for assessing the patient's overall health and identifying any potential complications such as infection or anemia. However, this action is not the immediate priority. The nurse must first ensure that the patient's airway is clear and that there are no life-threatening conditions that need immediate attention.
Choice C: Inspect the mouth for signs of inhalation injuries
Inspecting the mouth for signs of inhalation injuries is the priority action. Burns to the face and chest can lead to inhalation injuries, which can cause airway obstruction and respiratory distress. Early identification and management of inhalation injuries are critical to prevent respiratory failure. Signs of inhalation injury may include soot around the mouth or nose, singed nasal hairs, and difficulty breathing. Ensuring the airway is clear and managing any inhalation injuries takes precedence over other actions.
Choice D: Insert an indwelling urinary catheter
Inserting an indwelling urinary catheter can be important for monitoring urine output, which is a key indicator of renal function and fluid balance in burn patients. However, this action is not the immediate priority. The nurse must first address any potential airway issues before proceeding with other interventions.
Correct Answer is B
Explanation
Choice A Reason:
0.9% sodium chloride is an isotonic crystalloid solution often used for fluid resuscitation. However, it is not the preferred choice for burn patients because it lacks the necessary electrolytes to replace those lost through burn injuries. While it can be used if Lactated Ringer's is unavailable, it does not provide the same balanced electrolyte composition.
Choice B Reason:
Lactated Ringer's is the preferred fluid for initial resuscitation in burn patients. It is an isotonic crystalloid solution that closely mimics the body's plasma, providing essential electrolytes such as sodium, potassium, calcium, and lactate. The lactate in the solution acts as a buffer, helping to correct metabolic acidosis, which is common in burn patients. The Parkland formula, widely used for calculating fluid needs in burn patients, specifically recommends Lactated Ringer's for the first 24 hours.
Choice C Reason:
Dextrose 5% in water is a hypotonic solution that provides free water and calories but lacks electrolytes. It is not suitable for initial fluid resuscitation in burn patients because it does not address the electrolyte imbalances and large fluid shifts that occur after a burn injury. Using this solution could lead to further complications such as hyponatremia.
Choice D Reason:
Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that provides both glucose and electrolytes. However, it is not typically used for initial burn resuscitation because the high glucose content can lead to hyperglycemia, which is detrimental to burn patients. Additionally, the solution's osmolarity can exacerbate fluid shifts and worsen edema.
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