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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is correct because a client who is short of breath is in immediate danger, as it indicates a possible respiratory compromise or failure. The nurse should assess the client's oxygen saturation, respiratory rate, and lung sounds, and provide oxygen therapy as needed.
Choice B Reason: This is incorrect because a client who received oral pain medication 30 min ago is not in immediate danger, as it indicates that the client's pain has been managed and the medication has had time to take effect.
Choice C Reason: This is incorrect because a client who is scheduled for an abdominal x-ray and is awaiting transport is not in immediate danger, as it indicates that the client's condition is stable and the diagnostic test is not urgent.
Choice D Reason: This is incorrect because a client who has a prescription for discharge is not in immediate danger, as it indicates that the client's condition has improved and the client is ready to leave the hospital.
Correct Answer is D
Explanation
Choice A Reason: This choice is incorrect because providing a brightly lit environment may stimulate the client and increase the intracranial pressure. A brightly lit environment is an environment that has a high level of illumination or brightness. It may be used for clients who have depression, seasonal affective disorder, or insomnia, but it does not help to reduce the intracranial pressure.
Choice B Reason: This choice is incorrect because teaching controlled coughing and deep breathing may increase the intrathoracic pressure and increase the intracranial pressure. Controlled coughing and deep breathing are techniques that help to clear the airway and improve lung expansion. They may be used for clients who have respiratory infections, chronic obstructive pulmonary disease, or postoperative complications, but they do not help to reduce the intracranial pressure.
Choice C Reason: This choice is incorrect because encouraging a minimum intake of 2000 mL (67.5 oz) of clear fluids per day may cause fluid overload and increase the intracranial pressure. 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, restricting fluid intake and using diuretics may be indicated for clients who have increased intracranial pressure.
Choice D Reason: This choice is correct because elevating the head of the bed 20° may help to improve the venous drainage and decrease the intracranial pressure. As explained above, positioning the client in a semi-Fowler's or high-Fowler's position can facilitate breathing and prevent further complications. However, elevating the head of the bed more than 30° may decrease the cerebral perfusion pressure (CPP), which is the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP). A normal CPP range is 70 to 100 mm Hg, and a low CPP (<50 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, elevating the head of the bed to a moderate angle (20°) may be optimal for clients who have increased ICP.
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