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.

Answer and Explanation

The Correct Answer is D

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: Checking the oximeter is also important, but not the first action that the nurse should take. The oximeter measures the oxygen saturation of the blood, which reﬂects the adequacy of gas exchange in the lungs. The nurse should maintain the oxygen saturation above 90%, and administer supplemental oxygen as prescribed.

However, these measures are secondary to ensuring adequate oxygenation and perfusion.

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: Monitoring for manifestations of increased intracranial pressure is the first action that the nurse should take. Increased intracranial pressure can result from bleeding, swelling, or ﬂuid accumulation in the brain, which can compress and damage brain tissue and blood vessels. The nurse should assess for signs and symptoms of increased intracranial pressure, such as headache, nausea, vomiting, altered level of consciousness, pupillary changes, or Cushing's triad (bradycardia, hypertension, and irregular respirations). The nurse should also intervene to prevent or reduce increased intracranial pressure, such as elevating the head of the bed, maintaining normothermia, and administering osmotic diuretics. Monitoring for manifestations of increased intracranial pressure is essential to prevent further brain injury and preserve neurological function.

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Correct Answer is B

Explanation

Choice A Reason: Infection is a serious complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should monitor the client's wound healing, temperature, white blood cell count, and signs of sepsis, and administer antibiotics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice B Reason: Airway obstruction is the priority risk for assessment and intervention for a client who has burns of the head, neck, and chest. The nurse should assess the client's airway patency, respiratory rate, oxygen saturation, breath sounds, and signs of respiratory distress, such as stridor, wheezes, or cyanosis. The nurse should also provide humidified oxygen, suction secretions, elevate the head of the bed, and prepare for endotracheal intubation if needed. Airway obstruction can occur due to edema, inﬂammation, or inhalation injury of the upper airway, and can quickly lead to hypoxia, respiratory failure, and death.

Choice C Reason: Paralytic ileus is a potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's bowel sounds, abdominal distension, nausea, vomiting, and stool output, and administer ﬂuids, electrolytes, and nutritional support as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice D Reason: Fluid imbalance is another potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's ﬂuid status, urine output, vital signs, weight, and serum electrolytes, and administer intravenous ﬂuids as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

A. Hemodynamic status B. Spinal cord perfusion C. Renal function D. Intracranial pressure

Correct Answer is A

Explanation

Choice A Reason: This is correct because a pulmonary artery catheter is a device that measures the pressures and ﬂows in the heart and lungs, such as the pulmonary artery pressure, the pulmonary artery wedge pressure, the cardiac output, and the mixed venous oxygen saturation. These parameters reﬂect the hemodynamic status of the client, which is the balance between the cardiac output and the systemic vascular resistance.

Choice B Reason: This is incorrect because a pulmonary artery catheter does not measure spinal cord perfusion, which is the blood ﬂow to the spinal cord. Spinal cord perfusion can be aﬀected by spinal cord injury, spinal anesthesia, or spinal surgery.

Choice C Reason: This is incorrect because a pulmonary artery catheter does not measure renal function, which is the ability of the kidneys to filter waste products and maintain ﬂuid and electrolyte balance. Renal function can be assessed by urine output, blood urea nitrogen, creatinine, and glomerular filtration rate.

Choice D Reason: This is incorrect because a pulmonary artery catheter does not measure intracranial pressure, which is the pressure inside the skull. Intracranial pressure can be increased by brain injury, stroke, tumor, infection, or hydrocephalus.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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