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 D

Explanation

Choice A reason:

While preparing the gastrointestinal tract for enteral feedings is important, it is not the primary reason for administering famotidine. Famotidine is typically used to reduce gastric acid production, not to prepare the GI tract for feedings.

Choice B reason:

Increasing the motility of the gastrointestinal tract is not the primary function of famotidine. Famotidine is an H2 receptor antagonist that works by decreasing the production of stomach acid.

Choice C reason:

Keeping the gastrointestinal tract functioning normally is a broad statement and does not specifically address the reason for administering famotidine. The drug's role in preventing stress ulcers is more relevant to the patient's current condition.

Choice D reason:

Famotidine is used to prevent stress ulcers, which can occur in critically ill patients, including those on mechanical ventilation. The stress of illness and mechanical ventilation increases the risk of developing gastric ulcers, and famotidine helps reduce this risk by decreasing gastric acid secretion.

A. Specific gravity. B. Level of consciousness. C. Urine output. D. Blood pressure.

Correct Answer is C

Explanation

Choice A reason:

A decrease in specific gravity is not the primary therapeutic outcome of desmopressin in the treatment of diabetes insipidus. Desmopressin works by increasing water reabsorption in the kidneys, which leads to a decrease in urine output and an increase in urine concentration, reflected by an increase, not a decrease, in specific gravity.

Choice B reason:

A decrease in the level of consciousness is not an intended therapeutic outcome and would be concerning if observed. Desmopressin aims to control symptoms of diabetes insipidus, not alter the patient’s mental status.

Choice C reason:

A decrease in urine output is the primary therapeutic outcome of desmopressin in a patient with diabetes insipidus. Desmopressin mimics the action of antidiuretic hormone (ADH), leading to increased water reabsorption in the kidneys and reduced urine volume.

Choice D reason:

Desmopressin does not primarily aim to decrease blood pressure. Its main effect is on water reabsorption in the kidneys, thereby reducing urine output. While it can have some impact on blood pressure, this is not its primary therapeutic outcome.

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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?

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Naxlex Comprehensive Predictor Exams

A client is on mechanical ventilation and the client's spouse wonders why famotidine is needed since the client "only has lung problems." What response by the nurse is best?

Correct Answer is D

Explanation

A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving desmopressin. The nurse understands the therapeutic outcome is a decrease in:

Correct Answer is C

Explanation

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