A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Slow the rate to 50 mL/hr.

Increase the rate to 250 mL/hr.

Slow the rate to 20 mL/hr.

Continue the rate at 125 mL/hr.

Answer and Explanation

The Correct Answer is C

Choice A Reason: This choice is incorrect because slowing the rate to 50 mL/hr may not be enough to prevent cerebral edema, which is a common complication of head injury. Cerebral edema is a swelling of the brain tissue due to increased ﬂuid accumulation. It can cause increased intracranial pressure (ICP), which can lead to brain damage or death. Therefore, the nurse should limit the ﬂuid intake of the client with head injury to avoid worsening the condition.

Choice B Reason: This choice is incorrect because increasing the rate to 250 mL/hr may cause ﬂuid overload, which can also increase the ICP and worsen the cerebral edema. Fluid overload is a condition in which the body has too much ﬂuid, which can impair the function of the heart, lungs, and kidneys. Therefore, the nurse should avoid giving too much ﬂuid to the client with head injury.

Choice C Reason: This choice is correct because slowing the rate to 20 mL/hr may help to maintain adequate hydration and electrolyte balance, while preventing ﬂuid overload and cerebral edema. This is a conservative approach that can be used until the client's neurological status and ICP are assessed and monitored.

Choice D Reason: This choice is incorrect because continuing the rate at 125 mL/hr may not be appropriate for the client with head injury, depending on their individual needs and condition. The nurse should adjust the ﬂuid rate according to the client's vital signs, urine output, serum osmolality, and ICP. Therefore, the nurse should not assume that this rate is optimal for the client without further evaluation.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2, indicating that the client is hyperventilating and losing too much carbon dioxide.

Choice B Reason: This is incorrect because metabolic acidosis is characterized by a low pH and a low bicarbonate level, indicating that the client has an excess of metabolic acids or a loss of base.

Choice C Reason: This is incorrect because metabolic alkalosis is characterized by a high pH and a high bicarbonate level, indicating that the client has an excess of base or a loss of metabolic acids.

Choice D Reason: This is correct because respiratory acidosis is characterized by a low pH and a high PaCO2, indicating that the client is hypoventilating and retaining too much carbon dioxide.

A. Increased urine output B. Decreased blood glucose level C. Decreased blood pressure D. Increased heart rate

Correct Answer is A

Explanation

Choice A Reason: Dobutamine is a positive inotropic agent that increases the contractility of the heart and improves cardiac output. This leads to increased renal perfusion and urine output, which reduces the ﬂuid overload and edema associated with heart failure. Therefore, this choice is correct.

Choice B Reason: Dobutamine does not have a direct eﬀect on blood glucose level. It may cause hyperglycemia as a side eﬀect, but this is not an indication of its eﬀectiveness. Therefore, this choice is incorrect.

Choice C Reason: Dobutamine may cause a slight decrease in blood pressure due to vasodilation, but this is not its main therapeutic eﬀect. A significant decrease in blood pressure may indicate hypovolemia, hypotension, or shock, which are adverse eﬀects of dobutamine. Therefore, this choice is incorrect.

Choice D Reason: Dobutamine also has a positive chronotropic eﬀect, which means it increases the heart rate. However, this is not a desired outcome for a client with heart failure, as it increases the oxygen demand of the heart and may worsen the condition. Therefore, this choice is incorrect.

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A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Nursing Test Bank

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