A patient has a traumatic brain injury. The nurse assesses the following: Pulse change from 82 to 60 beats/min, Pulse pressure increase from 26 to 40 mm Hg, and Respiratory irregularities. What action by the nurse takes priority?

Increase the rate of the IV fluid administration.

Notify the provider immediately.

Prepare to give IV pain medication.

Notify respiratory therapy for a breathing treatment.

Answer and Explanation

The Correct Answer is B

Choice A reason: Increasing the rate of IV fluid administration is not the priority action in this situation. Although maintaining adequate fluid levels is important for patients with traumatic brain injuries, the symptoms described (pulse change, increased pulse pressure, and respiratory irregularities) indicate that the patient may be experiencing increased intracranial pressure (ICP). Fluid administration alone will not address this issue and could potentially worsen the condition if not managed carefully.

Choice B reason: The priority action is to notify the provider immediately. The changes in vital signs (decreased pulse, increased pulse pressure, and respiratory irregularities) suggest that the patient may be experiencing increased intracranial pressure (ICP), which is a medical emergency. Immediate notification of the provider is essential for timely intervention to prevent further neurological damage or complications.

Choice C reason: Preparing to give IV pain medication is not the priority in this situation. While managing pain is important, the patient's vital sign changes indicate a more serious underlying issue (potential increased intracranial pressure) that requires immediate medical attention. Pain medication alone will not address the root cause of the symptoms.

Choice D reason: Notifying respiratory therapy for a breathing treatment is not the priority action in this scenario. Although respiratory irregularities are present, the vital sign changes suggest that the patient is experiencing increased intracranial pressure. This requires immediate medical intervention by the provider to manage the underlying condition, rather than solely focusing on respiratory support.

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Correct Answer is C

Explanation

Choice A reason: Repositioning the patient frequently and promoting deep breathing are important interventions for various conditions, particularly for preventing atelectasis and respiratory complications. However, they are not directly related to preventing the most common serious complication of peritoneal dialysis, which is peritonitis.

Choice B reason: Infusing the dialysate slowly can help manage discomfort and ensure proper fluid exchange during peritoneal dialysis. However, it does not address the most serious complication, which is infection.

Choice C reason: Using strict aseptic technique in dialysis procedures is crucial in preventing peritonitis, the most serious and common complication of peritoneal dialysis. Peritonitis is an infection of the peritoneal cavity and can lead to severe complications if not prevented. Adhering to aseptic techniques during catheter insertion, connection, disconnection, and any other procedure involving the dialysis system is essential to reduce the risk of infection.

Choice D reason: Having the patient empty the bowel before the inflow phase can help ensure adequate space in the peritoneal cavity for the dialysate and prevent discomfort. However, this action does not directly prevent the serious complication of peritonitis.

A. pH 7.50, pO2 85, pCO2 35, HCO3 30 mEq/L B. pH 7.30, pO2 90, pCO2 35, HCO3 20 mEq/L C. pH 7.50, pO2 95, pCO2 25, HCO3 22 mEq/L D. pH 7.30, pO2 80, pCO2 55, HCO3 22 mEq/L

Correct Answer is D

Explanation

Choice A reason: The values pH 7.50, pO2 85, pCO2 35, HCO3 30 mEq/L indicate alkalosis with a high bicarbonate level, which is not consistent with the patient’s slow respiratory rate that would typically lead to respiratory acidosis.

Choice B reason: The values pH 7.30, pO2 90, pCO2 35, HCO3 20 mEq/L indicate metabolic acidosis with normal pCO2, which does not align with the respiratory issue described (hypoventilation).

Choice C reason: The values pH 7.50, pO2 95, pCO2 25, HCO3 22 mEq/L indicate respiratory alkalosis, which is characterized by a low pCO2. This is not consistent with the patient’s hypoventilation, which would lead to elevated pCO2 levels.

Choice D reason: The values pH 7.30, pO2 80, pCO2 55, HCO3 22 mEq/L indicate respiratory acidosis, which aligns with the patient’s hypoventilation due to anesthesia effects and incisional pain. The elevated pCO2 and decreased pH are consistent with reduced respiratory rate and shallow breathing.

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A patient has a traumatic brain injury. The nurse assesses the following: Pulse change from 82 to 60 beats/min, Pulse pressure increase from 26 to 40 mm Hg, and Respiratory irregularities. What action by the nurse takes priority?

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To prevent the most common serious complication of peritoneal dialysis, it is important for the nurse to:

Correct Answer is C

Explanation

A nurse is caring for a post-operative patient with a respiratory rate of 9 breaths/minute secondary to general anesthesia effects and incisional pain. Which arterial blood gas (ABG) would the nurse anticipate?

Correct Answer is D

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