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

Answer and Explanation

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.

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Correct Answer is ["0.5"]

Explanation

To administer the correct dose of Morphine, the nurse needs to calculate the volume of medication to deliver 1 mg of Morphine. Since the medication is supplied in a concentration of 2 mg per 1 mL, the nurse would administer half of the volume of the vial to provide the ordered 1 mg dose. Therefore, the nurse should administer 0.5 mL of Morphine to the patient.

Correct Answer is ["1.3"]

Explanation

To calculate the dosage of clindamycin, first convert the patient's weight from pounds to kilograms, knowing that 1 kg equals 2.2 lbs. The patient weighs 88 lbs, which is equivalent to 40 kg (88 lbs / 2.2 lbs per kg). The prescribed dose is 10 mg/kg/day, so the patient requires 400 mg/day (10 mg/kg * 40 kg). Since the medication is to be administered in two divided doses, each dose will be half of the daily requirement, resulting in 200 mg per dose. The medication is supplied at a concentration of 150 mg/mL, so to find out how many milliliters per dose, divide the dose in milligrams by the concentration: 200 mg / 150 mg/mL, which equals 1.33 mL. Rounded to the nearest tenth, the nurse will administer 1.3 mL per dose.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is ordered 1 mg of Morphine IV push. The medication is supplied in vials 2 mg/1 mL. What should the nurse administer? (round to the nearest tenth)

Correct Answer is ["0.5"]

Explanation

A physician prescribes clindamycin 10 mg/kg/day IV in two divided doses for respiratory tract infection. The medication is supplied 150 mg/mL. The patient weighs 88 lbs. How much will the nurse administer per dose? (round to the nearest tenth)

Correct Answer is ["1.3"]

Explanation

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