A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

Prepare the client for an MRl of the brain.

Administer mannitol IV bolus to the client.

Determine the client's Glasgow Coma Scale score.

D insert an indwelling urinary catheter for the client.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Determine the client’s Glasgow Coma Scale score. This is because the Glasgow Coma Scale (GCS) is a tool to assess the level of consciousness and neurological status of a client who has a closed head injury. The GCS score can help guide the priority of interventions and the need for further diagnostic tests.

Choice A is wrong because an MRI of the brain is not the first action to take for a client who has a closed head injury. An MRI may be indicated later to evaluate the extent of brain damage, but it is not an emergency procedure.

Choice B is wrong because mannitol IV bolus is a medication that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue. However, mannitol should not be administered before confirming the presence and degree of increased ICP, which can be done by measuring the GCS score and other vital signs.

Choice D is wrong because inserting an indwelling urinary catheter for the client is not the first action to take for a client who has a closed head injury. A urinary catheter may be needed to monitor fluid balance and renal function, but it is not an urgent intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is choice B. Apply direct pressure to the puncture site.

Choice A rationale:

Applying intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site is not the best approach. This method may not effectively control the bleeding and could potentially dislodge the introducer sheath.

Choice B rationale:

Applying direct pressure to the puncture site is the most effective way to control bleeding. Direct pressure helps to promote clot formation and reduce blood flow to the area, which is crucial in managing postoperative bleeding.

Choice C rationale:

Elevating the affected extremity above the level of the heart is not appropriate in this situation. While elevation can reduce swelling, it does not address the immediate need to control active bleeding.

Choice D rationale:

Leaving the dressing undisturbed and notifying the physician immediately is not advisable. Immediate action to control the bleeding is necessary before notifying the physician. Delaying intervention could lead to significant blood loss.

A. Compare the clients current weight with preprocedure weight B. Examine for leakage at the site of the procedure. C. Check the client’s serum albumin levels D. Confirm that the client is able to urinate

Correct Answer is A

Explanation

The correct answer is choice A. Comparing the client’s current weight with preprocedure weight is the best way to evaluate the effectiveness of the paracentesis, which is a procedure to remove excess fluid from the abdominal cavity. The fluid buildup, or ascites, is a common complication of end-stage liver disease (ESLD), which is a condition in which the liver is severely damaged and cannot function adequately.

Choice B is wrong because examining for leakage at the site of the procedure is not a measure of effectiveness, but a potential complication that should be monitored and reported.

Choice C is wrong because checking the client’s serum albumin levels is not relevant to the paracentesis.

Albumin is a protein that helps maintain fluid balance in the body, but it is not affected by the removal of fluid from the abdomen.

Choice D is wrong because confirming that the client is able to urinate is not related to the paracentesis.

Urination is a function of the kidneys, not the liver, and it does not reflect the amount of fluid removed from the abdomen.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing.

Correct Answer is B

Explanation

A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?

Correct Answer is A

Explanation

A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?

A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?

A nurse in an emergency department is caring for a client. Exhibits The nurse is preparing to discharge the client. Which of the following statements by the client indicate an understanding of the discharge teaching? Select all that apply.

A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching?

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client

A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?

A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?

A nurse is performing postmortem care for a recently deceased client prior to the client’s family visit. Which of the following actions should the nurse plan to take?