The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?
Suction the patient to minimize secretions
Continue with the assessment and document the finding
Notify the physician and raise HOB to 35-45 degrees
Lower the head of the bed and pad the side rails
The Correct Answer is C
A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.
B. Documenting without intervention could lead to worsening of the patient's condition.
C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.
D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Discussing over-the-counter drugs with the healthcare provider is essential, as they can interact with antiepileptic medications.
B. Discontinuing antiepileptic medications abruptly can lead to rebound seizures and is unsafe, so this statement is correct.
C. Doubling up on doses can lead to toxicity and adverse effects; missed doses should not be made up by doubling the next dose. This response indicates the need for further teaching.
D. Taking medications exactly as prescribed is necessary to maintain therapeutic levels and manage seizure control effectively.
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