The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

Encourage the patient to cough to expectorate secretions

Elevate the head of the bed to 30-45 degrees

Stimulate the patient with active range of motion exercises

Perform serial neurologic assessments while hospitalized

Contact the healthcare provider if the ICP is sustained between 30-40mmHg

Answer and Explanation

Correct Answer : B,D,E

A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.

B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.

C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.

D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.

E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications

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Correct Answer is ["16"]

Explanation

To calculate the dosage of Vancomycin, first convert the patient's weight from pounds to kilograms, knowing that 1 kg equals 2.2 lbs. The patient weighs 110 lbs, which is equivalent to 50 kg (110 lbs / 2.2). Next, multiply the patient's weight in kilograms by the prescribed dosage of 20 mg/kg, resulting in a total dosage of 1000 mg (50 kg * 20 mg/kg). Since the vials contain 500 mg per 8 mL, divide the total dosage required by the amount per vial to find out how many milliliters should be withdrawn. This results in 16 mL (1000 mg / (500 mg/8 mL)).

Correct Answer is ["3"]

Explanation

To administer the correct dose of clonidine, which is 0.3 mg, the nurse would need to calculate the number of 0.1 mg tablets required. Since each tablet contains 0.1 mg of clonidine, the nurse would need three tablets to make up the total dose of 0.3 mg. Therefore, the nurse should administer three tablets per dose to the patient.

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The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A physician prescribes Vancomycin 20 mg/kg intravenous (IV). The patient weighs 110 lbs. The medication is available in vials which contain 500 mg per 8 mL. What should the nurse withdraw from the vial? (round to the nearest whole number)

Correct Answer is ["16"]

Explanation

A nurse is preparing to administer clonidine 0.3 mg at bedtime to a patient. The amount available is clonidine 0.1 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["3"]

Explanation

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