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 A
Explanation
Choice A Reason: This choice is correct because allowing the drainage to drip onto a sterile gauze pad may help to identify if it is cerebrospinal fluid (CSF), which is a clear fluid that surrounds and protects the brain and spinal cord. CSF leakage from the nose (rhinorrhea) may indicate a basilar skull fracture, which is a serious injury that can cause intracranial bleeding, infection, or brain damage. The nurse should test the drainage for the presence of glucose or the halo sign, which are indicators of CSF.
Choice B Reason: This choice is incorrect because obtaining a culture of the specimen using sterile swabs may introduce bacteria into the nasal cavity and increase the risk of infection. The nurse should avoid inserting anything into the nose or mouth of a client who has a suspected basilar skull fracture.
Choice C Reason: This choice is incorrect because inserting sterile packing into the nares may increase the pressure in the cranial cavity and worsen the injury. The nurse should avoid applying pressure or occluding the nose or ears of a client who has a suspected basilar skull fracture.
Choice D Reason: This choice is incorrect because suctioning the nose gently with a bulb syringe may damage the nasal mucosa and cause bleeding. The nurse should avoid suctioning or irrigating the nose or ears of a client who has a suspected basilar skull fracture.
Correct Answer is A
Explanation
Choice A Reason: Packed RBCs are indicated for clients who have hypovolemic shock due to blood loss, as they increase the oxygen-carrying capacity of the blood and restore the blood volume.
Choice B Reason: Cryoprecipitates are indicated for clients who have hemophilia or von Willebrand disease, as they contain clotting factors that help stop bleeding.
Choice C Reason: Albumin is indicated for clients who have hypovolemic shock due to fluid loss, such as from burns or ascites, as it increases the plasma oncotic pressure and draws fluid into the vascular space.
Choice D Reason: Platelets are indicated for clients who have thrombocytopenia or platelet dysfunction, as they help prevent or control bleeding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today