A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?

Flex the client's hip.

Hyperextend the client's neck.

Provide warming measures for the client.

Adjust the client's head of bed.

Answer and Explanation

The Correct Answer is D

A. Flex the client’s hip is incorrect. Flexing the hip can increase intra-abdominal pressure and potentially increase intracranial pressure.

B. Hyperextend the client’s neck is incorrect. Hyperextension of the neck can interfere with venous return from the brain and increase ICP.

C. Provide warming measures for the client is incorrect. Warming measures are not indicated for a low CPP; maintaining normothermia is important, but warming is not the priority action.

D. Adjust the client’s head of bed is correct. Elevating the head of the bed helps reduce ICP and improves cerebral perfusion by promoting venous outflow.

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Correct Answer is []

Explanation

Condition:

A. Transfusion-associated circulatory overload (TACO)

Rationale: The client’s symptoms—dyspnea, restlessness, crackles in the lungs, jugular vein distension, and elevated blood pressure—are consistent with TACO, a condition resulting from excessive fluid volume during a blood transfusion.

Actions to Take:

C. Administer furosemide

Rationale: Furosemide is a diuretic that helps reduce fluid overload, which is a key issue in TACO.

B. Administer diphenhydramine

Rationale: Although not the primary treatment for TACO, diphenhydramine can help manage symptoms if there is a mild allergic reaction contributing to the situation.

Parameters to Monitor:

A. Intake and output

Rationale: Monitoring intake and output helps assess fluid balance and effectiveness of treatment for TACO.

D. Weight

Rationale: Weight monitoring helps assess fluid overload and effectiveness of diuretic therapy

A. Blockage of the ET tube by the client's tongue B. Movement of the ET tube into the right main bronchus C. Infection of the vocal cords D. Passage of the ET tube into the esophagus

Correct Answer is B

Explanation

A. Blockage of the ET tube by the client's tongue would not typically result in asymmetric chest wall expansion.
B. If the ET tube has moved into the right main bronchus, it will cause more air to enter the right lung and less to the left, leading to decreased left-sided chest wall expansion.
C. Infection of the vocal cords is not related to the absence of chest wall expansion.
D. Passage of the ET tube into the esophagus would lead to the absence of breath sounds in both lungs, not just the left side.

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A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Correct Answer is B

Explanation

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