A nurse is caring for a client with a traumatic brain injury in the ICU. The client’s intracranial pressure (ICP) is 22 mm Hg. Which intervention should the nurse implement first?

Administer IV mannitol

Elevate the head of the bed to 30 degrees

Initiate seizure prophylaxis

Increase sedation

Answer and Explanation

The Correct Answer is B

Choice A reason: IV mannitol reduces intracranial pressure by drawing fluid from brain tissue, but it requires a provider’s order and time to act. ICP of 22 mm Hg is elevated, and elevating the head of the bed is a non-invasive, immediate intervention to promote venous drainage, making it the priority action.

Choice B reason: An ICP of 22 mm Hg indicates elevated intracranial pressure, risking brain herniation. Elevating the head of the bed to 30 degrees promotes cerebral venous drainage, reducing ICP immediately. This non-invasive intervention aligns with the ABCDE approach’s focus on preventing neurological deterioration, making it the first action in traumatic brain injury management.

Choice C reason: Seizure prophylaxis prevents complications in traumatic brain injury but does not directly address elevated ICP (22 mm Hg). Seizures increase ICP further, but immediate pressure reduction is critical to prevent herniation. Head elevation is a faster, non-invasive intervention, making seizure prophylaxis secondary in this acute scenario.

Choice D reason: Increasing sedation controls agitation, which can raise ICP, but it risks respiratory depression and requires careful monitoring. ICP of 22 mm Hg needs immediate reduction, and head elevation promotes venous drainage without delay. Sedation is a supportive measure, making it less urgent than positioning to lower ICP.

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Correct Answer is B

Explanation

Choice A reason: Pain medication is important for burn patients due to severe pain from exposed nerve endings. However, in the ABCDE approach, circulation (fluid status) takes precedence over pain management. A 30% burn causes significant fluid loss, risking hypovolemic shock, making IV fluids the priority to stabilize the patient before addressing pain.

Choice B reason: A 30% burn injury to the lower extremities causes significant plasma leakage, leading to hypovolemia and potential shock. Administering IV fluids, typically via the Parkland formula, restores intravascular volume, maintains blood pressure, and ensures organ perfusion. In the ABCDE approach, circulation is prioritized, making fluid resuscitation the first intervention.

Choice C reason: Cleaning and dressing burn wounds prevent infection, a major complication due to loss of the skin barrier. However, this is not the immediate priority in the acute phase. Fluid resuscitation addresses life-threatening hypovolemia first, as per the ABCDE approach, ensuring circulatory stability before wound care is initiated.

Choice D reason: A tetanus booster prevents infection from Clostridium tetani, especially in contaminated burns. While important, it is not the first priority in the acute management of a 30% burn. Fluid resuscitation addresses immediate life-threatening hypovolemia, which takes precedence over prophylactic measures like tetanus vaccination in the ABCDE framework.

A. Administer IV insulin B. Initiate oral glucose administration C. Administer IV sodium bicarbonate D. Restrict fluid intake

Correct Answer is A

Explanation

Choice A reason: In DKA, hyperglycemia and ketoacidosis cause fruity breath and Kussmaul respirations (rapid, deep breathing) as the body compensates for acidosis. IV insulin halts ketone production, corrects hyperglycemia, and reverses acidosis, addressing the primary metabolic disturbance. This is the priority intervention to stabilize the client and prevent further acid-base imbalance.

Choice B reason: Oral glucose administration is contraindicated in DKA, as it worsens hyperglycemia. Fruity breath and Kussmaul respirations indicate severe metabolic acidosis from ketone accumulation. Insulin is needed to lower blood glucose and stop ketogenesis, making glucose administration harmful and inappropriate for managing this life-threatening condition.

Choice C reason: IV sodium bicarbonate may correct severe acidosis (pH <7.0) in DKA but is not the first-line intervention. Insulin therapy addresses the root cause by reducing hyperglycemia and ketone production, naturally correcting pH. Fruity breath and respirations indicate ongoing acidosis, making insulin the priority over bicarbonate in initial management.

Choice D reason: Restricting fluid intake is contraindicated in DKA, which causes dehydration from osmotic diuresis. Fruity breath and Kussmaul respirations reflect acidosis and compensatory hyperventilation. IV fluids and insulin are needed to restore volume and correct metabolic imbalances, making fluid restriction harmful and inappropriate for this critical condition.

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A nurse is caring for a client with a traumatic brain injury in the ICU. The client’s intracranial pressure (ICP) is 22 mm Hg. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

Correct Answer is B

Explanation

A client with diabetic ketoacidosis (DKA) is admitted to the ICU. The nurse notes a fruity breath odor and rapid, deep respirations. Which intervention should the nurse prioritize?

Correct Answer is A

Explanation

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