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 A

Explanation

Choice A Reason: Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system, which can compromise the drainage of air and ﬂuid from the pleural space and impair lung expansion.

Choice B Reason: Occasional bubbling in the water-seal chamber is normal and expected, as it indicates that air is being removed from the pleural space.

Choice C Reason: Fluctuations in the ﬂuid level in the water-seal chamber are normal and expected, as they reﬂect changes in intrathoracic pressure during inspiration and expiration.

Choice D Reason: Constant bubbling in the suction-control chamber is normal and expected, as it indicates that suction is being applied to the chest tube system.

A. Fluid overload B. Intracardiac shunt C. Hypovolemia D. Left ventricular failure

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because ﬂuid overload is a condition of excess ﬂuid volume in the body. A client who has ﬂuid overload is more likely to have a high CVP, which indicates increased pressure in the right atrium and vena cava.

Choice B Reason: This is incorrect because an intracardiac shunt is a condition of abnormal blood ﬂow between the chambers of the heart. A client who has an intracardiac shunt may have a normal or high CVP, depending on the direction and magnitude of the shunt.

Choice C Reason: This is correct because hypovolemia is a condition of low ﬂuid volume in the body. A client who has hypovolemia is more likely to have a low CVP, which indicates decreased pressure in the right atrium and vena cava.

Choice D Reason: This is incorrect because left ventricular failure is a condition of impaired pumping function of the left ventricle. A client who has left ventricular failure may have a normal or high CVP, depending on the degree of backward failure and pulmonary congestion.

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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?

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