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 B

Explanation

Choice A reason:

A serum blood glucose level of 128 mg/dL is slightly elevated but not immediately concerning in the context of organ donation. Blood glucose levels can be managed with insulin if necessary, and this value does not indicate an acute issue requiring immediate intervention.

Choice B reason:

A blood pressure of 83/51 mmHg is critically low and requires immediate action. Low blood pressure can compromise organ perfusion and oxygen delivery, potentially leading to organ damage. In the context of organ donation, maintaining adequate perfusion pressure is essential to ensure the viability of the organs for transplantation.

Choice C reason:

A hemoglobin level of 13 g/dL is within the normal range and does not require immediate intervention. Hemoglobin levels are important for oxygen-carrying capacity but are not the priority concern six hours before organ harvesting if the value is within normal limits.

Choice D reason:

A core body temperature of 97.8 degrees F is slightly below normal but not immediately alarming. Mild hypothermia can be addressed with warming measures, and this temperature does not indicate a critical issue that requires urgent action.

A. Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain. B. Lorazepam 2 mg IV now for the client experiencing restlessness and picking at tubing. C. Morphine sulfate 4 mg IV now for the client experiencing incisional pain. D. One unit packed red blood cells STAT for the client with hemoglobin of 9.5 g/dL.

Correct Answer is A

Explanation

Choice A reason:

Administering Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain should be the nurse's priority because chest pain can be indicative of a myocardial infarction (heart attack), which is a medical emergency. Quick administration of Nitroglycerin can help to relieve chest pain, improve blood flow to the heart, and prevent further cardiac damage.

Choice B reason:

While administering Lorazepam 2 mg IV for the client experiencing restlessness and picking at tubing is important for patient safety and comfort, it is not as urgent as addressing potential cardiac issues indicated by chest pain.

Choice C reason:

Administering Morphine sulfate 4 mg IV for incisional pain management is necessary for the patient’s comfort and pain control but is not as critical as treating potential life-threatening chest pain.

Choice D reason:

Administering one unit of packed red blood cells STAT for the client with a hemoglobin of 9.5 g/dL is important but does not take precedence over the immediate risk of a myocardial infarction. The hemoglobin level, while low, is not immediately life-threatening compared to the chest pain scenario.

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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

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Correct Answer is B

Explanation

The nurse receives new orders for multiple clients. Which order should be the nurse's priority?

Correct Answer is A

Explanation

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