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 B
Explanation
Choice A rationale
Neutrogena is a brand that produces skin care products, not a topical corticosteroid.
Choice B rationale
Triamcinolone is a topical corticosteroid used to treat inflammation and other symptoms of psoriasis by reducing immune response and inflammation.
Choice C rationale
Coal tar is used in the treatment of psoriasis but is not a corticosteroid.
Choice D rationale
Methotrexate is an immunosuppressant used for severe cases of psoriasis but is not a topical corticosteroid.
Correct Answer is D
Explanation
Choice A rationale
The occipital lobe is responsible for processing visual information and does not play a significant role in spatial relationships.
Choice B rationale
The frontal lobe is involved in higher cognitive functions, decision-making, and voluntary movements, but it is not primarily responsible for spatial relationships.
Choice C rationale
The temporal lobe is involved in auditory processing, language comprehension, and memory formation. It is not primarily responsible for spatial relationships.
Choice D rationale
The parietal lobe is responsible for processing sensory information and plays a crucial role in spatial relationships, helping to understand and navigate the environment.
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