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 B

Explanation

A. Suction subglottic area above the ETT cuff before entering the ETT. While subglottic suctioning helps prevent ventilator-associated pneumonia (VAP) by removing pooled secretions, it does not directly improve oxygenation during deep endotracheal suctioning. The priority is to optimize oxygenation before and after suctioning.
B. Use the ventilator settings to stack breaths prior to suctioning. Pre-oxygenating the client by delivering additional breaths via the ventilator helps prevent hypoxia during suctioning. Closed suction systems momentarily interrupt airflow, which can lead to oxygen desaturation. Providing 100% FiO₂ for 30–60 seconds before suctioning helps ensure adequate oxygenation and reduces complications.
C. Rinse suction catheters with normal saline between each suction pass. Flushing the catheter keeps it clean and patent, but it does not enhance oxygenation. Normal saline instillation before suctioning is not recommended, as it can increase infection risk and worsen secretion mobilization.
D. Suction for 30 seconds with each pass of the suction catheter. Prolonged suctioning can cause severe hypoxia, bradycardia, and airway trauma. Suction passes should be limited to 10–15 seconds to minimize complications. If additional suctioning is needed, the client should be reoxygenated between passes.

Correct Answer is ["5"]

Explanation

Calculation:

Calculate the New Nitroglycerin Dose in mcg/hour

Dose (mcg/hour) = Dose (mcg/min) × 60 min/hour

=15 mcg/min × 60 min/hour = 900 mcg/hour

Convert mcg to mg

Dose (mg/hour) = Dose (mcg/hour) / 1000 mcg/mg

=900 mcg/hour / 1000 mcg/mg

= 0.9 mg/hour

Calculate the Concentration of Nitroglycerin in the IV Bag

Concentration (mg/mL) = Total mg of Nitroglycerin / Total mL of Solution

=50 mg / 250 mL

= 0.2 mg/mL

Calculate the Infusion Rate = Infusion Rate (mL/hour)

=0.9 mg/hour / 0.2 mg/mL

= 4.5 mL/hour

Round to the Nearest Whole Number

4.5 mL/hour rounded to 5 mL/hour

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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

Correct Answer is B

Explanation

Correct Answer is ["5"]

Explanation

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