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.
The Correct Answer is D
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: Reducing the infusion to 20 mL/hr is excessively low and may cause hypotension or inadequate maintenance of vascular access and medication delivery. Such a drastic decrease could impair perfusion to injured brain tissue and is not an appropriate independent nursing action without a specific order.
Choice D reason: Maintaining the current prescribed infusion rate avoids abrupt volume shifts that could alter intracranial pressure. The nurse should monitor neurologic status and vital signs, ensure the IV is patent, and follow provider orders; only change the rate when clinically indicated or when directed by the prescriber.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Urine output is not a finding that should decrease with adequate fluid replacement. On the contrary, urine output should increase as the fluid therapy restores the renal perfusion and function. The nurse should monitor the urine output and ensure that it is at least 0.5 mL/kg/hr for adults and 1 mL/kg/hr for children.
Choice B Reason: Heart rate is a finding that should decrease with adequate fluid replacement. A high heart rate is a sign of hypovolemia, which occurs when the burn injury causes fluid loss from the intravascular space. The nurse should monitor the heart rate and expect it to decrease as the fluid therapy replenishes the blood volume and improves the cardiac output.
Choice C Reason: Weight is not a finding that should decrease with adequate fluid replacement. On the contrary, weight may increase as the fluid therapy restores the hydration status and corrects the fluid deficit. The nurse should monitor the weight and compare it with the pre-burn weight to evaluate the fluid balance.
Choice D Reason: Blood pressure is not a finding that should decrease with adequate fluid replacement. On the contrary, blood pressure may increase as the fluid therapy restores the vascular tone and improves the tissue perfusion. The nurse should monitor the blood pressure and expect it to increase as the fluid therapy compensates for the fluid loss.
Correct Answer is ["B","D","E"]
Explanation
Choice A Reason: This choice is incorrect because headache is not a common manifestation of ARF. Headache may be caused by various factors such as dehydration, stress, sinusitis, or migraine, but it does not indicate ARF.
Choice B Reason: This choice is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a difficulty or discomfort in breathing that affects the oxygen delivery and carbon dioxide removal from the body. It may be caused by various factors such as lung disease, heart disease, anemia, or anxiety, but it indicates ARF when it is severe and persistent.
Choice C Reason: This choice is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of uneasiness or discomfort in the stomach that may precede vomiting. It may be caused by various factors such as food poisoning, motion sickness, medication side effects, or pregnancy, but it does not indicate ARF.
Choice D Reason: This choice is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal (less than 90/60 mm Hg). It may be caused by various factors such as dehydration, blood loss, sepsis, or shock, but it indicates ARF when it is due to reduced cardiac output or vasodilation from hypoxia.
Choice E Reason: This choice is correct because decreased level of consciousness is a common manifestation of ARF. Decreased level of consciousness is a condition in which the person has impaired awareness or responsiveness to stimuli. It may be caused by various factors such as brain injury, stroke, seizure, or drug overdose, but it indicates ARF when it is due to increased carbon dioxide levels (hypercapnia) or decreased oxygen levels (hypoxemia) in the brain.
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