Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?
Beware of changes in ICP related to leaking cerebrospinal fluid (CSF)
Maintain hyper-oxygenation through use of a ventilator
Use strict aseptic technique with all procedural dressing changes
Administer IV mannitol (Osmitrol)
The Correct Answer is C
A. Monitoring for CSF leakage is crucial to avoid infection and to maintain ICP accuracy.
B. Hyper-oxygenation may be used in certain cases but is not the priority.
C. Aseptic technique for all procedures and dressing changes is critical to prevent infection.
D. Administering IV mannitol can be important, but aseptic technique is the priority to prevent infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Shivering is a common response to cold therapy (such as a hypothermia blanket) as the body attempts to maintain its core temperature. This can increase metabolic demands and oxygen consumption, which should be closely monitored.
B. Seizures are not typically associated with the use of hypothermia blankets unless there are underlying conditions that predispose to them.
C. Dehydration could occur with any prolonged therapy but is not the immediate concern with hypothermia blankets.
D. Burns are rare but could occur if the hypothermia blanket is not properly managed. Shivering is a more immediate concern.
Correct Answer is C
Explanation
A. Hypertension is a modifiable risk factor for stroke, not a nonmodifiable one.
B. Obesity is a modifiable risk factor, as lifestyle changes can affect weight.
C. Genetics are a nonmodifiable risk factor, as family history cannot be changed and increases stroke risk.
D. History of smoking is a modifiable risk factor. Stopping smoking reduces stroke risk.
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