An adult client with a closed head injury was admitted to the intensive care unit (ICU) one hour ago following a motor vehicle collision. The client's telemetry displays normal sinus rhythm. After placing an intraventricular cannula for intracranial pressure monitoring, the healthcare provider (HCP) prescribes protocols for IV infusions of mannitol and dopamine. Which nursing intervention has the highest priority?

Observe vital signs sequences as a way of assessing for Cushing's triad.

Evaluate hourly urinary output.

Monitor arterial blood pressure.

Assess intracranial pressure following intracranial transducer placement.

Answer and Explanation

The Correct Answer is D

A. Observe vital signs sequences as a way of assessing for Cushing's triad. Cushing’s triad (hypertension with widened pulse pressure, bradycardia, and irregular respirations) is a late sign of increased intracranial pressure (ICP). While monitoring for it is important, early recognition and direct ICP monitoring are more effective in preventing deterioration.
B. Evaluate hourly urinary output. Mannitol is an osmotic diuretic that can cause significant diuresis, requiring close monitoring of urine output to prevent dehydration and electrolyte imbalances. However, assessing ICP is the priority because increased ICP can cause brain herniation, which is life-threatening.
C. Monitor arterial blood pressure. Dopamine is a vasopressor used to maintain cerebral perfusion pressure (CPP), which is crucial in head injury management. While blood pressure monitoring is essential, directly assessing ICP ensures that treatment is effective in preventing secondary brain injury.
D. Assess intracranial pressure following intracranial transducer placement. The highest priority is monitoring ICP immediately after placement to detect dangerous elevations that could lead to herniation. The intraventricular catheter provides real-time pressure readings, guiding interventions like mannitol administration and blood pressure control to optimize cerebral perfusion and prevent worsening neurological damage.

Nursing Test Bank

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Correct Answer is ["9"]

Explanation

Calculation:

Calculate the dopamine dose in mcg/min:

Dose = 2 mcg/kg/min

Weight = 60 kg

Dose per minute = 2 mcg/kg/min × 60 kg

= 120 mcg/min

Calculate the dopamine dose in mcg/hour:

Dose per hour = 120 mcg/min × 60 min/hour

= 7200 mcg/hour

Convert mcg to mg:

Dose per hour = 7200 mcg/hour / 1000 mcg/mg

= 7.2 mg/hour

Calculate the concentration of dopamine in the IV bag:

Dopamine: 400 mg

Solution: 500 mL

Concentration = 400 mg / 500 mL

= 0.8 mg/mL

Calculate the infusion rate in mL/hour:

Dose per hour: 7.2 mg/hour

Concentration: 0.8 mg/mL

Infusion rate = 7.2 mg/hour / 0.8 mg/mL

= 9 mL/hour

A. Place a cooling blanket on the client. B. Administer an antipyretic agent. C. Give a 500 mL IV fluid bolus challenge. D. Titrate IV vasopressor for systolic less than 80.

Correct Answer is C

Explanation

A. Place a cooling blanket on the client. A temperature of 100°F (37.8°C) is only mildly elevated and does not require active cooling. The priority concern is hemodynamic instability due to hypovolemia, not fever management. Cooling blankets are typically used for high fevers (≥ 102°F or 38.9°C).
B. Administer an antipyretic agent. While fever may indicate postoperative infection or inflammatory response, the client’s most critical issue is hypotension and low urine output, suggesting hypovolemia or early shock. Treating the underlying cause (fluid loss) is more urgent than giving an antipyretic.
C. Give a 500 mL IV fluid bolus challenge. The client has tachycardia (132 bpm), hypotension (88/65 mm Hg), and oliguria (10 mL/hour), all of which suggest hypovolemic shock, a common postoperative complication. A fluid bolus (typically 500–1000 mL of isotonic crystalloid such as normal saline or lactated Ringer’s) is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.
D. Titrate IV vasopressor for systolic less than 80. Vasopressors (e.g., norepinephrine) are not the first-line treatment for hypovolemic shock. Fluids should be administered first to correct volume loss before considering vasopressors. If hypotension persists despite adequate fluid resuscitation, vasopressors may be initiated.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider (HCP) prescribes dopamine 2 mcg/kg/min IV for client who weighs 60 kg. The IV bag contains "Dopamine 400 mg in dextrose 5% in water (DW) 500 mL." The nurse should program the infusion pump to deliver how many mL/hour? (Enter numerical value only.)

Correct Answer is ["9"]

Explanation

Correct Answer is C

Explanation

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