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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can cause ﬂuid overload and pulmonary edema in a client who has burns.

Choice B Reason: This is incorrect because dextrose 5% in water is a hypotonic solution that can cause ﬂuid shifts from the intravascular space to the interstitial space, resulting in hypovolemia and hypotension in a client who has burns.

Choice C Reason: This is incorrect because 0.9% sodium chloride is an isotonic solution that can cause hypernatremia and hyperchloremia in a client who has burns, as the ﬂuid loss from burns is greater than the sodium loss.

Choice D Reason: This is correct because lactated Ringer's is an isotonic solution that contains electrolytes similar to plasma, such as sodium, potassium, calcium, and chloride. It also contains lactate, which is converted to bicarbonate in the liver and helps correct the metabolic acidosis that occurs in a client who has burns.

A. Furosemide B. Heparin C. Dexamethasone D. Epinephrine E. Atropine

Correct Answer is B

Explanation

Choice A Reason: This choice is incorrect because furosemide is a diuretic that helps to reduce ﬂuid retention and edema. It may be used for clients who have heart failure or hypertension, but it does not treat pulmonary embolism.

Choice B Reason: This choice is correct because heparin is an anticoagulant that helps to prevent blood clots from forming or growing larger. It may be used for clients who have pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot that usually originates from a deep vein thrombosis (DVT). Heparin can reduce the risk of complications such as pulmonary infarction or death.

Choice C Reason: This choice is incorrect because dexamethasone is a corticosteroid that helps to reduce inﬂammation and immune response. It may be used for clients who have allergic reactions, asthma, or autoimmune diseases, but it does not treat pulmonary embolism.

Choice D Reason: This choice is incorrect because epinephrine is a sympathomimetic that helps to stimulate the heart and blood vessels. It may be used for clients who have cardiac arrest, anaphylaxis, or severe asthma, but it does not treat pulmonary embolism.

Choice E Reason: This choice is incorrect because atropine is an anticholinergic that helps to block the eﬀects of acetylcholine on the heart and smooth muscles. It may be used for clients who have bradycardia, atrioventricular block, or organophosphate poisoning, but it does not treat pulmonary embolism.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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