To evaluate the effectiveness of mannitol, the nurse should monitor:
Sodium level.
Fluid intake.
Heart rate.
Urine output.
The Correct Answer is D
Choice A reason:
Monitoring sodium levels is important when administering mannitol, but it is not the primary indicator of the drug's effectiveness. Mannitol is an osmotic diuretic used to reduce intracranial pressure, and its effectiveness is better assessed by other means.
Choice B reason:
Fluid intake is important to monitor to ensure proper hydration status, but it does not directly indicate the effectiveness of mannitol. The primary focus should be on the patient's output to assess the diuretic effect.
Choice C reason:
Heart rate monitoring is essential for overall patient care but does not directly indicate the effectiveness of mannitol. Changes in heart rate can occur due to various factors and are not specific to mannitol's action.
Choice D reason:
Urine output is the most direct measure of mannitol's effectiveness. As an osmotic diuretic, mannitol promotes diuresis, and increased urine output indicates that the drug is effectively reducing intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Providing small doses of opioid analgesia is important for pain management, but it is not the highest priority in a patient with a closed head injury on mechanical ventilation. Pain control should be balanced with the need to monitor neurological status.
Choice B reason:
Maintaining pCO2 of 35-45 is critical for patients with a closed head injury on mechanical ventilation. Proper pCO2 levels help manage intracranial pressure (ICP) and prevent secondary brain injury. Hyperventilation to lower pCO2 can reduce ICP but must be carefully controlled to avoid cerebral ischemia.
Choice C reason:
Administering an anti-anxiety agent can help manage agitation and anxiety, but it is not the highest priority. Sedation must be used cautiously in head injury patients to avoid masking changes in neurological status.
Choice D reason:
Monitoring blood pressure every four hours is necessary for overall patient care, but continuous monitoring and immediate interventions are more critical in managing intracranial pressure and preventing secondary brain injury.
Correct Answer is A
Explanation
Choice A reason:
A heart rate of 45 beats/min (bradycardia) is concerning because it indicates a significant impact on the autonomic nervous system, which can occur with high thoracic spinal cord injuries. Bradycardia can lead to inadequate cardiac output and may require immediate intervention to prevent further cardiovascular compromise.
Choice B reason:
An SpO2 of 91% is slightly below normal but not immediately life-threatening. While monitoring and addressing oxygen saturation is important, it is not as critical as the hemodynamic instability indicated by bradycardia in this context.
Choice C reason:
A blood pressure of 98/62 mmHg is on the lower end of the normal range but not immediately alarming. While hypotension is a concern in spinal cord injury patients, the more pressing issue in this scenario is the bradycardia, which can have more immediate and severe consequences.
Choice D reason:
Loss of motor and sensory function in the extremities is a significant finding in spinal cord injuries and indicates the level and severity of the injury. However, it is not immediately life-threatening and does not require as urgent intervention as bradycardia in this acute setting.
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