A nurse is assessing a client who has increased intracranial pressure (ICP). The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

Pupillary dilation

Decorticate posturing

Altered level of consciousness

Cheyne-Stokes respirations

Answer and Explanation

The Correct Answer is C

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

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Correct Answer is A

Explanation

Practice standards indicateblood should be infused through a 20-gauge or larger catheter to prevent hemolysis [destruction] of red blood cells. Y tubing with 0.9% sodium chloride is used to administer blood products is not necessary.A unit of packed RBCs should be administered over 2 to 4 hours, unless otherwise ordered by the provider, to reduce the risk of fluid overload and transfusion reactions . The client's vital signs should be obtained before, during (15 minutes after starting and every hour thereafter), and after the transfusion to monitor for any signs of adverse reactions.

A. Obtain consent for surgery. B. Insert an indwelling urinary catheter. C. Apply antiembolic stockings. D. Insert an NG tube.

Correct Answer is A

Explanation

The nurse's priority is to ensure that the client has given informed consent for the surgery, which requires that the client is competent and understands the risks and benefits of the procedure. A client with a high blood alcohol level may not have the mental capacity to consent and may need a legal representative or a court order to proceed with the surgery.

The other actions are important but not as urgent as obtaining consent.

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A nurse is assessing a client who has increased intracranial pressure (ICP). The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a unit of packed RBCS to a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

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