You have a patient who has a ventriculostomy drain in place for intracranial pressure monitoring and continuous cerebral spinal fluid drainage. As the primary RN what will you do to ensure an accurate reading of the ICP waveform?
Make sure patient is laying flat
Close the drain to stop CSF drainage for 6 minutes
Empty drainage tube
Check patient's vital signs
The Correct Answer is B
A. Make sure patient is laying flat is incorrect because the head of the bed should generally be elevated to 30 degrees to promote venous drainage and reduce ICP. Laying flat may actually increase intracranial pressure and does not ensure an accurate ICP waveform reading.
B. Close the drain to stop CSF drainage for 6 minutes is correct because when the ventriculostomy is open to drain CSF, the ICP reading may not reflect true intracranial pressure, as CSF is continuously leaving the ventricles. To obtain an accurate ICP waveform, the nurse temporarily clamps or closes the drain for a short period (typically 5–10 minutes) while monitoring the patient, then documents the reading. This ensures the waveform reflects actual intracranial pressure rather than the pressure altered by ongoing drainage.
C. Empty drainage tube is incorrect because draining CSF from the collection chamber does not directly affect ICP waveform accuracy. The waveform represents ventricular pressure, and emptying the tube does not change the measurement as long as the system remains patent.
D. Check patient's vital signs is incorrect because while vital signs are important for overall assessment and detecting signs of increased ICP, they do not ensure an accurate ICP waveform reading. Vital signs can indicate changes secondary to ICP but are not a substitute for waveform assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Blood pressure 89/60 is correct because hypotension is a common and serious complication during hemodialysis. Rapid removal of fluid from the vascular system can lead to decreased perfusion to vital organs, including the heart and brain, and may result in dizziness, syncope, or shock. This requires immediate nursing intervention, such as slowing or pausing ultrafiltration, administering IV fluids, and monitoring hemodynamic status.
B. Urine output >300 mL/24 hr is incorrect because this indicates some residual kidney function, which is expected in many dialysis patients, especially those with acute kidney injury or partial chronic kidney disease. It is not acutely concerning.
C. HR 100 is incorrect because mild tachycardia can be a compensatory responseto fluid shifts or stress during dialysis, but it is less immediately dangerous than hypotension. Continuous monitoring is appropriate.
D. Productive cough is incorrect because while respiratory assessment is important, a cough does not represent an immediate hemodynamic threatduring dialysis unless associated with pulmonary edema or hypoxia.
Correct Answer is C
Explanation
A. They will likely need ICP monitoring is incorrect because a simple scalp laceration does not typically cause increased intracranial pressure. ICP monitoring is reserved for patients with suspected or confirmed brain injury, not isolated scalp injuries.
B. They will need continuous blood pressure and oxygen saturation monitoring is incorrect because while vital signs are routinely monitored in the ED, continuous cardiac and oxygen monitoring is not generally required for a minor scalp lacerationunless there are signs of hemodynamic instability or other injuries.
C. Holding pressure on the laceration because profuse bleeding can occur is correct. The scalp is highly vascular, and even a relatively small laceration can lead to significant blood loss. Immediate nursing care focuses on applying direct pressure, controlling bleeding, and preparing for wound closure(sutures, staples, or adhesive strips). Proper hemorrhage control is essential to prevent hypovolemia and shock.
D. You will need to make sure they have warm blankets to prevent temperature from decreasing is incorrect because hypothermia prevention is not a primary concernfor a patient with an isolated scalp laceration. While warming measures may be used in trauma patients with extensive blood loss or environmental exposure, it is not the main priorityin this scenario.
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