After a craniotomy, the nurse assesses the patient and finds generalized edema, decreased urine output, acute confusion, and muscle weakness. The client has IV fluids running at 75 mL/hr. What action should the nurse take first?

Assess the client's serum sodium level.

Continue to monitor the client's urinary output.

Increase the rate of the IV infusion.

Administer desmopressin IV per protocol.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Assessing the client's serum sodium level is the priority action. The symptoms of generalized edema, decreased urine output, acute confusion, and muscle weakness are suggestive of possible hyponatremia or other electrolyte imbalances, which can be critical in the postoperative period following a craniotomy. Checking the serum sodium level will provide essential information to guide further treatment.

Choice B reason:

While continuing to monitor the client's urinary output is important, it does not address the immediate need to diagnose and correct a potential electrolyte imbalance. The nurse needs to take action to determine the underlying cause of the patient's symptoms.

Choice C reason:

Increasing the rate of the IV infusion could potentially worsen the patient's condition, especially if the symptoms are related to fluid overload or electrolyte imbalance. This action should only be taken based on specific clinical indications and after appropriate assessments.

Choice D reason:

Administering desmopressin IV per protocol is not appropriate as the first action without confirming the underlying cause of the symptoms. Desmopressin is used for specific conditions such as diabetes insipidus, and its administration should be based on a confirmed diagnosis.

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Correct Answer is C

Explanation

Choice A reason:

The application of PEEP does not inherently increase the need for FiO2 (fraction of inspired oxygen) administration. PEEP helps improve oxygenation, potentially reducing the need for higher FiO2 levels.

Choice B reason:

While PEEP can contribute to better lung inflation by keeping the alveoli open, this is a secondary effect. The primary goal of PEEP is to prevent alveolar collapse at the end of expiration.

Choice C reason:

PEEP prevents alveolar collapse during expiration, which is its primary therapeutic effect. By maintaining a certain level of pressure in the lungs at the end of expiration, PEEP ensures that the alveoli remain open, improving gas exchange and oxygenation.

Choice D reason:

Although PEEP can help reduce the risk of atelectasis (collapse of part or all of a lung), it does not directly prevent barotrauma. Barotrauma is related to high airway pressures, and careful monitoring of ventilator settings is necessary to avoid it.

A. Temperature of 96.8°F B. Blood pressure 110/68 C. Respiratory rate of 20 breaths/min D. Heart rate of 70 beats/min

Correct Answer is B

Explanation

Choice A reason:

A temperature of 96.8°F is within the normal range for a human body (97.8°F to 99.1°F). However, it does not necessarily indicate the desired effect of Dopamine. Dopamine is primarily used to improve blood flow and cardiac output, particularly in critically ill patients. Therefore, temperature alone is not a reliable indicator of its effectiveness.

Choice B reason:

Blood pressure of 110/68 mmHg suggests that the Dopamine is effectively maintaining the patient's hemodynamic stability. Dopamine is often used to support blood pressure in patients with hypotension, particularly after spinal cord injuries. Maintaining an adequate blood pressure ensures that vital organs receive sufficient blood flow, which is a key therapeutic goal of Dopamine administration.

Choice C reason:

A respiratory rate of 20 breaths/min is considered normal for an adult (12-20 breaths/min). While normal respiratory rate is a positive sign, it is not a direct measure of Dopamine's effectiveness. Dopamine's primary action is on the cardiovascular system, so a normal respiratory rate alone does not necessarily indicate that the drug is having the desired effect.

Choice D reason:

A heart rate of 70 beats/min is within the normal range for adults (60-100 beats/min). Similar to the respiratory rate, while a normal heart rate is beneficial, it is not a direct indicator of Dopamine's effectiveness. Dopamine's role in improving cardiac output and blood pressure is more critical in assessing its desired effects.

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After a craniotomy, the nurse assesses the patient and finds generalized edema, decreased urine output, acute confusion, and muscle weakness. The client has IV fluids running at 75 mL/hr. What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

Correct Answer is C

Explanation

The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

Correct Answer is B

Explanation

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