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 B

Explanation

Choice A Reason: Equal amount of ﬂuid drainage in each collection chamber is not a sign of proper chest tube function. The amount of ﬂuid drainage depends on the type and extent of the client's injury or surgery, and may vary from one chamber to another.

Choice B Reason:Fluctuation of the fluid level in the water seal chamber(tidaling) indicates that the chest tube is functioning properly. This fluctuation corresponds with the client's respirations and shows that air or fluid is being effectively removed from the pleural space.

Choice C Reason:Continuous bubbling within the water seal chamber: Continuous bubbling in the water seal chamber indicates an air leak, which is not normal unless the client has a pneumothorax and air is being evacuated. Otherwise, it suggests a problem with the system.

Choice D Reason: Absence of ﬂuid in the drainage tubing is not a sign of proper chest tube function. It may indicate that the chest tube is obstructed, kinked, or clamped, or that the suction is not working properly. The nurse should assess and troubleshoot the chest tube system.

A. Administer a nitrate antihypertensive. B. Obtain the client's heart rate. C. Assess the client for bladder distention. D. Place the client in a high-Fowler's position.

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because administering a nitrate antihypertensive is not the first action, as it may cause a rapid drop in blood pressure and worsen the client's condition.

Choice B Reason: This is incorrect because obtaining the client's heart rate is not the first action, as it does not address the cause of autonomic dysreﬂexia or relieve the symptoms.

Choice C Reason: This is incorrect because assessing the client for bladder distention is not the first action, as it may take time and delay the treatment of autonomic dysreﬂexia.

Choice D Reason: This is correct because placing the client in a high-Fowler's position is the first action, as it lowers the blood pressure by promoting venous return and reducing cardiac preload.

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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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Naxlex Comprehensive Predictor Exams

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

Correct Answer is B

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreﬂexia. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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