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?

Elevate the head of the bed and provide a pillow under the client's head.

Suction the endotracheal tube every 15 minutes to reduce choking.

Intersperse treatments and nursing care with frequent rest periods.

Change positions frequently while providing basic nursing care.

Answer and Explanation

The Correct Answer is C

A. Elevate the head of the bed and provide a pillow under the client's head. While elevating the head of the bed to 30 degrees can help reduce ICP by promoting venous drainage, placing a pillow under the head may cause neck flexion, which can obstruct venous outflow and worsen intracranial pressure. Instead, the head should be maintained in a neutral midline position without excessive flexion or extension.
B. Suction the endotracheal tube every 15 minutes to reduce choking. Frequent suctioning can increase ICP due to coughing and vagal stimulation. Suctioning should be performed only as needed and using minimized suction duration to prevent sudden rises in intracranial pressure.
C. Intersperse treatments and nursing care with frequent rest periods. Clustering too many nursing interventions together can overstimulate the client and cause spikes in ICP. Providing adequate rest periods between activities such as repositioning, suctioning, and assessments allows intracranial pressure to return to baseline levels, helping to prevent sustained increases.
D. Change positions frequently while providing basic nursing care. Frequent repositioning can cause sudden fluctuations in ICP, especially if movements are abrupt or cause venous obstruction. Turning the client slowly and maintaining the head in a neutral position is recommended to avoid exacerbating intracranial hypertension.

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Correct Answer is A

Explanation

A. Document that the client is experiencing a paced rhythm. A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.
B. Reposition the ECG leads and obtain another recording. If the ECG showed artifact, lead displacement, or interference, repositioning the leads might be appropriate. However, the presence of consistent pacemaker spikes before each QRS complex suggests proper pacemaker function rather than a lead issue.
C. Assess the client for symptoms of decreased cardiac output. A paced rhythm is expected after pacemaker insertion and does not necessarily indicate hemodynamic instability. While assessment is always important, there is no indication that the client is experiencing decreased cardiac output symptoms such as hypotension, dizziness, or altered mental status.
D. Notify the healthcare provider (HCP) of the telemetry recording. Routine paced rhythms do not require immediate provider notification unless there are malfunctions such as failure to capture, failure to sense, or failure to pace. Since the pacemaker is functioning appropriately, notifying the HCP is unnecessary.

A. Expel the excess air and heparin from the syringe. B. Place sample in arterial blood gas syringe. C. Obtain a minimum of 1 mL of blood. D. Aspirate the blood sample slowly.

Correct Answer is C

Explanation

A. Expel the excess air and heparin from the syringe. While removing excess air prevents gas exchange alterations, this is not the priority when obtaining an SVO₂ sample. Excess heparin could dilute the sample, but proper blood volume collection is the first concern.
B. Place sample in arterial blood gas syringe. SVO₂ measures venous oxygen saturation, which is different from arterial blood gases (ABGs). Using an ABG syringe is incorrect because it is heparinized for arterial sampling, and arterial blood does not reflect mixed venous oxygenation.
C. Obtain a minimum of 1 mL of blood. SVO₂ is measured from the distal lumen of a pulmonary artery (PA) catheter to assess oxygen delivery and consumption. At least 1 mL of blood is required for an accurate reading, ensuring sufficient sample volume for laboratory analysis.
D. Aspirate the blood sample slowly. While slow aspiration can help prevent hemolysis, it is not the primary concern when collecting an SVO₂ sample. The priority is obtaining a sufficient volume (≥1 mL) for an accurate measurement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The nurse is collecting a blood sample for a mixed venous oxygen saturation (SVO2) level from the distal lumen of a pulmonary artery (PA) catheter of a client in cardiogenic shock. Which action should the nurse implement?

Correct Answer is C

Explanation

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