A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care?

Suction the client every 2 hr.

Maintain ICP at 20 mm Hg

Avoid overstimulation of the client.

Keep the client in a supine position.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Suction the client every 2 hr: Frequent suctioning can increase intracranial pressure due to stimulation of the airway and coughing reflex. Suctioning should be performed only when necessary and with careful monitoring of ICP, rather than routinely every 2 hours.

B. Maintain ICP at 20 mm Hg: Normal ICP ranges from 5 to 15 mm Hg. An ICP of 20 mm Hg or higher indicates increased intracranial pressure and requires intervention. Planning to maintain ICP at this elevated level is unsafe and not appropriate for care planning.

C. Avoid overstimulation of the client: Minimizing noise, unnecessary procedures, and environmental stimuli helps prevent spikes in ICP. Overstimulation can increase cerebral metabolic demand and worsen intracranial hypertension, so this intervention supports ICP management and neurologic stability.

D. Keep the client in a supine position: Supine positioning can impair venous drainage from the brain, potentially increasing ICP. Elevating the head of the bed to 30 degrees while maintaining spinal precautions is preferred to promote venous outflow and reduce intracranial pressure.

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Correct Answer is C

Explanation

Rationale:

A. Forearm: The forearm is not a recommended site for subcutaneous injections because it has limited subcutaneous tissue and is typically reserved for intradermal injections, such as allergy testing or tuberculosis screening.

B. Ventrogluteal: The ventrogluteal site is preferred for intramuscular injections due to the large muscle mass and low risk of nerve injury. It is not suitable for subcutaneous injections, which require fatty tissue rather than muscle.

C. Outer posterior aspect of upper arm: This site contains adequate subcutaneous tissue, is easily accessible, and is commonly used for subcutaneous injections such as insulin or heparin. It allows for proper absorption and minimizes the risk of intramuscular administration.

D. Vastus lateralis: The vastus lateralis is part of the thigh and is primarily used for intramuscular injections, especially in infants or adults needing large-volume IM medications. It is not a typical site for subcutaneous injections.

A. "I will change my baby's diaper at least every 4 hours." B. "I will wash the penis with soap and warm water until the circumcision has healed." C. "I will apply topical lidocaine following each diaper change." D. "I will apply an ice pack to my baby's penis twice daily to decrease swelling”

Correct Answer is A

Explanation

Rationale:

A. "I will change my baby's diaper at least every 4 hours.": Frequent diaper changes help keep the circumcision site clean and dry, reducing the risk of infection and irritation from urine or stool. Keeping the area free from moisture allows proper healing and minimizes discomfort for the newborn. This reflects correct home care following a circumcision.

B. "I will wash the penis with soap and warm water until the circumcision has healed.": Using soap on the circumcision site can cause irritation and delay healing. The area should be gently cleansed with warm water only, allowing the natural healing process to occur without additional chemical irritation from soaps or wipes containing alcohol or fragrances.

C. "I will apply topical lidocaine following each diaper change.": Topical anesthetics such as lidocaine are not recommended for routine circumcision care because they may cause toxicity or be absorbed unpredictably in newborns. Pain is managed through comfort measures such as swaddling, breastfeeding, or using petroleum jelly, not through anesthetic application.

D. "I will apply an ice pack to my baby's penis twice daily to decrease swelling.": Applying ice to a newborn’s circumcision site is unsafe and can cause tissue injury due to extreme temperature sensitivity. Mild swelling is expected and resolves naturally; the recommended care involves gentle cleansing and protecting the site with petroleum jelly not cold therapy.

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A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a subcutaneous injection to a client. Which of the following sites should the nurse choose?

Correct Answer is C

Explanation

A nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is A

Explanation

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