A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?
Respiratory status
Temperature
Intracranial pressure
Serum electrolytes
The Correct Answer is A
The correct answer is a. Respiratory status.
Choice A: Respiratory Status
Reason: After the evacuation of a subdural hematoma, monitoring the respiratory status is crucial. This is because changes in respiratory patterns can indicate increased intracranial pressure (ICP) or brainstem compression, which are life-threatening conditions. Ensuring that the airway is clear and that the patient is breathing adequately is the top priority. Normal respiratory rate for adults is 12-20 breaths per minute.
Choice B: Temperature
Reason: While monitoring temperature is important to detect infections or other complications, it is not the immediate priority in the acute postoperative period following a subdural hematoma evacuation. Fever can indicate infection, but it is less likely to cause immediate life-threatening complications compared to respiratory issues.
Choice C: Intracranial Pressure
Reason: Monitoring intracranial pressure (ICP) is very important in patients with brain injuries. Normal ICP ranges from 5-15 mmHg. However, changes in respiratory status can be an early indicator of increased ICP. Therefore, while ICP monitoring is critical, ensuring the patient’s respiratory status is stable takes precedence.
Choice D: Serum Electrolytes
Reason: Serum electrolytes are important to monitor for overall metabolic stability and to detect imbalances that could affect neurological function. Normal ranges for key electrolytes are: Sodium (135-145 mEq/L), Potassium (3.5-4.5 mEq/L), and Chloride (80-100 mEq/L). However, these are not the immediate priority in the acute phase following surgery compared to respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2, indicating that the client is hyperventilating and losing too much carbon dioxide.
Choice B Reason: This is incorrect because metabolic acidosis is characterized by a low pH and a low bicarbonate level, indicating that the client has an excess of metabolic acids or a loss of base.
Choice C Reason: This is incorrect because metabolic alkalosis is characterized by a high pH and a high bicarbonate level, indicating that the client has an excess of base or a loss of metabolic acids.
Choice D Reason: This is correct because respiratory acidosis is characterized by a low pH and a high PaCO2, indicating that the client is hypoventilating and retaining too much carbon dioxide.
Correct Answer is B
Explanation
Choice A Reason: According to the rule of nines, each arm accounts for 9 percent of the TBSA, and each leg accounts for 18 percent of the TBSA. Therefore, if the client has burns on both sides of both arms and legs, the total percentage would be (9 + 9 + 18 + 18) = 54 percent. However, this choice is incorrect because it does not account for the fact that the rule of nines applies only to adults, not children. For children, the percentages are different because their body proportions are different from adults.
Choice B Reason: This choice is correct because it uses the modified rule of nines for children. According to this rule, each arm accounts for 9 percent of the TBSA, and each leg accounts for 13.5 percent of the TBSA. Therefore, if the client has burns on both sides of both arms and legs, the total percentage would be (9 + 9 + 13.5 + 13.5) = 45 percent. However, this is not the final answer because it does not account for the fact that the rule of nines applies only to partial-thickness burns, not full-thickness burns. For full-thickness burns, the percentages are halved because they do not contribute to fluid loss as much as partial-thickness burns. Therefore, if the client has full-thickness burns on both sides of both arms and legs, the final percentage would be (4.5 + 4.5 + 6.75 + 6.75) = 22.5 percent. However, this is still not the final answer because it does not account for the fact that the rule of nines applies only to first- and second-degree burns, not third-degree burns. For third-degree burns, the percentages are doubled because they require more intensive care and treatment than first- and second-degree burns. Therefore, if the client has third- degree burns on both sides of both arms and legs, the final percentage would be (9 + 9 + 13.5 + 13.5) = 45 percent.
Choice C Reason: This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.
Choice D Reason: This choice is incorrect because it uses a random percentage that does not correspond to any rule or calculation.
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