The nurse is caring for a patient in the Intensive Care Unit (ICU) with a ventriculostomy and intracranial pressure (ICP) reading of 30mmHg. The nurse notes a widened pulse pressure, irregular respirations. and bradycardia. The neurosurgeon instructs the nurse to drain cerebrospinal fluid. The nurse would also anticipate which medication administration order from the provider?
3% Normal Saline
Nitroprusside
Norepinephrine
Furosemide
The Correct Answer is A
A) 3% Normal Saline:
Elevated ICP can lead to a life-threatening condition known as cerebral herniation, and it often triggers the Cushing’s triad—widened pulse pressure, bradycardia, and irregular respirations, all of which the nurse has noted. Hypertonic saline (such as 3% Normal Saline) is commonly used to manage increased ICP because it creates an osmotic gradient that draws fluid out of the brain tissue, reducing cerebral edema and lowering ICP. The goal is to reduce swelling and prevent further brain damage.
B) Nitroprusside:
Nitroprusside is a potent vasodilator that is used to treat hypertension and reduce afterload in conditions like heart failure or aortic dissection. However, in this case, nitroprusside is contraindicated because it could cause a drop in systemic blood pressure, which would worsen cerebral perfusion in a patient with elevated ICP.
C) Norepinephrine:
Norepinephrine is a vasopressor used to treat hypotension by increasing systemic vascular resistance and blood pressure. Although norepinephrine may be used to support blood pressure in critically ill patients, in this context of elevated ICP, the priority is to reduce ICP, not to increase blood pressure further. Increasing the systemic vascular resistance with norepinephrine could exacerbate ICP by increasing the volume of blood in the cranium
D) Furosemide:
Furosemide is a loop diuretic that can reduce fluid volume and help treat conditions like edema or heart failure. While furosemide can reduce overall fluid volume, it is not typically used to manage elevated ICP in this context. Diuretics like furosemide may have a role in managing cerebral edema, but they are not as effective as hypertonic saline in rapidly reducing ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["12"]
Explanation
Given:
Ordered dose of Heparin: 20 units/kg
Patient weight: 132 lbs
Concentration of Heparin: 25,000 units/250 mL (100 units/mL)
Step 1: Convert patient weight from pounds to kilograms:
1 pound (lb) = 0.453592 kilograms (kg)
Patient weight in kg = 132 lbs x 0.453592 kg/lb = 59.87424 kg
Step 2: Calculate the total dose of Heparin:
Total dose (units) = Ordered dose (units/kg) x Patient weight (kg)
Total dose (units) = 20 units/kg x 59.87424 kg
Total dose (units) = 1197.4848 units
Step 3: Calculate the volume to be administered:
Volume (mL) = Total dose (units) / Concentration (units/mL)
Volume (mL) = 1197.4848 units / 100 units/mL
Volume (mL) = 11.974848 mL
Step 4: Round to the nearest whole number:
Volume (mL) ≈ 12 mL
Correct Answer is B
Explanation
A) Monitoring the skin color and turgor:
While monitoring skin color and turgor is important in assessing fluid status and perfusion, it is not the immediate priority following an intracoronary stent insertion. Skin turgor is more useful in assessing dehydration or hypovolemia, but after a stent placement, the priority is to ensure the client is stable hemodynamically and there are no complications such as bleeding or thrombosis at the insertion site.
B) Monitoring the blood pressure every fifteen minutes:
Following an intracoronary stent insertion, it is crucial to monitor the client's blood pressure closely, as this procedure can lead to complications such as bleeding, clot formation, or vessel rupture. Monitoring blood pressure frequently (every 15 minutes initially) helps detect any signs of hypotension or hypertension that may indicate complications like bleeding or a clot.
C) Monitoring the cardiac enzymes every eight hours:
Cardiac enzymes, such as troponin, are typically used to assess myocardial injury and can be elevated in the setting of acute coronary syndrome. However, this is not the immediate priority post-procedure. The primary concern immediately after an intracoronary stent insertion is ensuring hemodynamic stability and preventing complications such as bleeding or thromboembolism, rather than focusing solely on enzyme levels.
D) Performing neurological checks every fifteen minutes:
Neurological checks are important in cases of stroke, neurological compromise, or complications like a clot dislodging. However, in the context of a patient who has just had an intracoronary stent placement, neurological checks are not the immediate priority unless there are signs of neurological symptoms (such as sudden weakness or confusion) that indicate a complication like an embolism or stroke.
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