When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?
Check the equipment.
Continue the assessment because no actions are indicated at this time.
Document the reading because it reflects that the treatment has been effective.
Contact the health care provider to review the care plan.
The Correct Answer is A
Choice A rationale
The nurse should check the equipment first when an ICP reading of 0 mm Hg is noted, as this may indicate equipment malfunction. An accurate ICP reading is critical for assessing and managing intracranial pressure to ensure the client's safety.
Choice B rationale
Continuing the assessment without checking the equipment may lead to incorrect conclusions based on a potentially faulty reading. It’s crucial to ensure the accuracy of the equipment before proceeding.
Choice C rationale
Documenting the reading as an effective treatment outcome without verifying its accuracy can be dangerous. An ICP reading of 0 mm Hg is unusual and warrants equipment verification.
Choice D rationale
Contacting the health care provider to review the care plan is premature until the equipment has been checked to rule out a false reading, ensuring the nurse provides accurate information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Scoliosis is characterized by a lateral curvature of the spine, often identified by uneven shoulders and a prominent scapula. The forward bending test accentuates these physical signs, helping to diagnose scoliosis.
Choice B rationale
Muscular dystrophy involves progressive muscle weakening and wasting, typically symmetrical, not causing the asymmetry seen in scoliosis. It usually doesn't present with the specific spinal curvature of scoliosis.
Choice C rationale
Kyphosis involves a forward rounding of the upper back, not a lateral curvature. It presents as a hunched or rounded back rather than uneven shoulders and prominent scapula.
Choice D rationale
Lordosis refers to an exaggerated inward curve of the lower back, not involving uneven shoulders or scapula. It affects the lumbar spine rather than presenting the scoliosis-related signs described.
Correct Answer is A
Explanation
Choice A rationale
Positioning the client flat as directed is the priority intervention after a lumbar puncture to prevent cerebrospinal fluid (CSF) leakage, which can lead to a post-lumbar puncture headache. This position helps maintain normal CSF pressure and promotes sealing of the puncture site.
Choice B rationale
Leaving the client to rest without performing any assessments is not appropriate, as continuous monitoring is necessary to detect any complications such as bleeding or changes in neurological status. Regular assessments help ensure timely intervention if issues arise.
Choice C rationale
Providing caffeine-rich drinks is sometimes recommended to alleviate headaches caused by CSF leakage post-lumbar puncture. However, it is not the priority intervention immediately after the procedure, which focuses on positioning and monitoring.
Choice D rationale
Avoiding analgesic agents is incorrect. Pain management is an important aspect of care post-lumbar puncture, and appropriate analgesics should be administered as needed. The focus should be on positioning and monitoring, not withholding pain relief.
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