The client is a 43-year-old male who had a surgical removal of a benign tumor from the left hemisphere of his brain. The client's estimated blood loss (EBL) is 100 mL during surgical procedure. There were no complications. Vital signs remained stable throughout the procedure. The client will be admitted to the neurological intensive care unit for monitoring.

Answer and Explanation

The Correct Answer is []

Place the call light within the client's reach. The client has undergone surgery on the left hemisphere of the brain, which controls speech and motor function on the right side. This may lead to temporary weakness or speech difficulties, making it essential to ensure easy access to the call light for assistance.
Use a word board to help the client communicate. Damage to the left hemisphere can result in Broca aphasia, where the client has difficulty producing speech but can still understand language. A word board or communication aid allows the client to express needs effectively despite speech limitations.
Cerebral perfusion pressure. Monitoring cerebral perfusion pressure (CPP) is essential after brain surgery to ensure the brain is receiving adequate blood flow. Low CPP can lead to ischemia, while high CPP may indicate increased intracranial pressure (ICP), both of which can result in serious complications.
Level of consciousness. Assessing neurological status frequently helps detect early signs of deterioration, such as worsening intracranial pressure, cerebral edema, or postoperative bleeding. Changes in alertness, responsiveness, or confusion may indicate a need for urgent intervention.
Broca aphasia. Since the left hemisphere controls speech production, surgery in this area may cause Broca aphasia, where the client understands language but struggles to form words or complete sentences. The use of alternative communication methods is necessary to assist the client in expressing their needs.
Prepare the client to return to surgery. There is no indication of complications requiring an immediate return to the operating room. The estimated blood loss (100 mL) is minimal, and vital signs remained stable throughout the procedure.
Give ibuprofen as ordered. Ibuprofen (a nonsteroidal anti-inflammatory drug - NSAID) is contraindicated postoperatively because it can increase the risk of bleeding by inhibiting platelet function. Acetaminophen is typically preferred for pain control.
Elevate the head of the bed to 45 degrees. After brain surgery, the head of the bed should be elevated to 30 degrees, not 45 degrees. This optimizes cerebral venous drainage while preventing excessive intracranial pressure (ICP) changes that could impair perfusion.
White blood cell count. WBC count may be monitored for infection, but immediate concerns after brain surgery focus on neurological status and cerebral perfusion rather than infection unless symptoms of fever or worsening condition develop.
Pupil response. While pupil assessment is a key neurological parameter, it is more relevant for clients at risk of brain herniation or severe ICP elevation. In this case, monitoring level of consciousness and cerebral perfusion pressure takes priority.
Deep tendon reflexes. Reflex testing is not a primary concern after brain surgery unless there are signs of spinal cord involvement or a progressive neurological disorder. Monitoring motor function and speech ability is more relevant.
Myasthenia gravis. Myasthenia gravis is an autoimmune neuromuscular disorder that causes muscle weakness but is unrelated to brain tumor removal.
Cushing response. Cushing's response is a late sign of increased intracranial pressure (ICP), characterized by hypertension, bradycardia, and irregular respirations. The client has no signs of worsening ICP at this time.
Hydrocephalus. Hydrocephalus is excess cerebrospinal fluid (CSF) accumulation, which typically requires a shunt or external ventricular drain (EVD). There is no indication of CSF buildup in this client.

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Correct Answer is B

Explanation

A. Notify healthcare provider (HCP) of the symptoms and administer a PRN pain medication. While notifying the HCP is necessary, administering pain medication does not address the underlying cause of the client’s acute chest pain and difficulty breathing. These symptoms suggest a possible pulmonary embolism (PE), a life-threatening complication after orthopedic surgery. Immediate supportive interventions should be initiated before notifying the provider.
B. Increase the client's IV flow rate and start low-flow oxygen. The client is experiencing acute respiratory distress, which could indicate a pulmonary embolism (PE), a fat embolism, or another postoperative complication. Providing oxygen helps improve oxygenation and reduce hypoxia, while increasing the IV flow rate helps maintain perfusion and prevent shock. These immediate interventions support vital functions while preparing for further medical management.
C. Position the client on the left side while immobilizing the affected leg. This position is used in air embolism management, not pulmonary embolism. In suspected PE, the priority is to optimize oxygenation and circulation rather than repositioning. The affected leg should be immobilized to prevent further embolization, but this is not the first priority.
D. Take the client's vital signs and auscultate all lung sounds. While assessing the client’s vital signs and lung sounds is important, intervention should not be delayed. The priority is to support oxygenation and circulation immediately, as PE can rapidly lead to hypoxia, hemodynamic instability, or cardiac arrest. Assessment should be done concurrently with emergency interventions.

A. Hyperglycemia. B. Hypotension. C. Paralytic ileus and abdominal distention. D. Muscle twitching and digit numbness.

Correct Answer is D

Explanation

A. Hyperglycemia. While elevated blood glucose can occur in acute pancreatitis due to pancreatic inflammation impairing insulin secretion, it is not an electrolyte imbalance. The question specifically asks about electrolyte-related manifestations.
B. Hypotension. Hypotension in acute pancreatitis is often due to fluid shifts (third-spacing) and systemic inflammation, rather than a direct electrolyte imbalance. Though dehydration and electrolyte losses can contribute to hypotension, this is not the most specific sign of an electrolyte disturbance.
C. Paralytic ileus and abdominal distention. Hypokalemia can lead to paralytic ileus, but ileus and distention are also caused by peritoneal irritation, inflammation, and impaired motility due to pancreatitis itself. While potassium imbalance could contribute, this is not the most direct electrolyte-related symptom.
D. Muscle twitching and digit numbness. Hypocalcemia is a common electrolyte imbalance in acute pancreatitis, caused by fatty acid breakdown binding calcium, leading to saponification. This results in neuromuscular excitability, causing muscle twitching, paresthesia (numbness/tingling), and positive Chvostek’s or Trousseau’s signs. These symptoms are clear indicators of an electrolyte disturbance related to pancreatitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Twelve hours following orthopedic surgery on the right leg, the client begins to have acute chest pain and difficulty breathing. Which action should the nurse take first?

Correct Answer is B

Explanation

The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?

Correct Answer is D

Explanation

An adult with head and facial injuries from a motor vehicle collision is fully immobilized and has a Glasgow coma score of 6. The client is intubated, sedated, and is being prepared for transfer to a regional trauma center. Which intervention(s) should the nurse implement? Select all that apply.

The nurse is monitoring for signs of increased intracranial pressure (ICP) in a client who attempted suicide by jumping from a tenth floor balcony. The client is intubated and mechanically ventilated. Which intervention should the nurse implement to minimize rises in ICP?

Exhibits Which are three goals of therapy for this client?

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.)

Exhibits Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply

The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?

After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?