A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
Check the oximeter.
Assess for an increase in temperature.
Monitor for manifestations of increased intracranial pressure.
The Correct Answer is B
Choice A Reason: Observing for cerebrospinal fluid (CSF) leaks from the evacuation site is important, but not the first action that the nurse should take. CSF leaks can indicate a breach in the dura mater, which can increase the risk of infection and meningitis. The nurse should inspect the dressing and the nose and ears for any clear or bloody drainage, and report any findings to the provider. However, these measures are secondary to ensuring adequate oxygenation and perfusion.
Choice B Reason: The first action the nurse should take when caring for a client post-evacuation of a subdural hematoma is to check the oximeter to ensure adequate oxygenation. Maintaining proper oxygenation is a priority because hypoxia and hypercapnia can lead to cerebral vasodilation, increasing intracranial pressure (ICP) and worsening neurological outcomes. Key Concept: Always prioritize Airway, Breathing, and Circulation (ABCs) when determining the most immediate nursing intervention.
Choice C Reason: Assessing for an increase in temperature is another important action, but not the first one that the nurse should take. An increase in temperature can indicate an infection, inflammation, or damage to the hypothalamus, which can affect the thermoregulation of the body. The nurse should monitor the temperature and administer antipyretics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and perfusion.
Choice D Reason:This is crucial, but oxygenation status should be checked first since low oxygen levels can worsen ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because fluid overload is a condition of excess fluid volume in the body. A client who has fluid overload is more likely to have a high CVP, which indicates increased pressure in the right atrium and vena cava.
Choice B Reason: This is incorrect because an intracardiac shunt is a condition of abnormal blood flow between the chambers of the heart. A client who has an intracardiac shunt may have a normal or high CVP, depending on the direction and magnitude of the shunt.
Choice C Reason: This is correct because hypovolemia is a condition of low fluid volume in the body. A client who has hypovolemia is more likely to have a low CVP, which indicates decreased pressure in the right atrium and vena cava.
Choice D Reason: This is incorrect because left ventricular failure is a condition of impaired pumping function of the left ventricle. A client who has left ventricular failure may have a normal or high CVP, depending on the degree of backward failure and pulmonary congestion.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because preparing for mechanical ventilation is not the priority nursing intervention, as it is an invasive and potentially harmful procedure that should be reserved for clients who have severe respiratory failure and cannot maintain adequate oxygenation with noninvasive methods.
Choice B Reason: This is correct because administering oxygen via face mask is the priority nursing intervention, as it is a noninvasive and effective way to improve oxygenation and reduce hypoxemia in a client who has low PaO2 and SaO2. Oxygen therapy can also decrease the workload of the heart and lungs and prevent further complications.
Choice C Reason: This is incorrect because preparing to administer a sedative is not the priority nursing intervention, as it may worsen the client's respiratory status and mask the signs and symptoms of hypoxemia. Sedatives should be used with caution and only after oxygenation has been optimized.
Choice D Reason: This is incorrect because assessing for indications of pulmonary embolism is not the priority nursing intervention, as it is a diagnostic rather than a therapeutic action. Pulmonary embolism is a possible cause of the client's condition, but it does not address the immediate problem of hypoxemia.
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