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 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.

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Free Nursing Study Resources

Correct Answer is ["24"]

Explanation

To find the concentration of heparin in the solution, divide the amount of heparin by the volume of D5W: 25,000 units / 500 mL = 50 units/mL
To find the infusion rate, divide the prescribed dose by the concentration: 1,200 units/hr / 50 units/mL = 24 mL/hr
Round the answer to the nearest tenth/whole number: 24 mL/hr

A. A client who is post-coronary artery bypass graft (CABG), has total cholesterol of 318 mg/dL, and is prescribed atorvastatin B. A client who has pneumonia, a WBC count of 11,500/mm³, and is prescribed piperacillin C. A client who has renal failure, a serum potassium of 5.8 mEq/L, and is prescribed sodium polystyrene sulfonate D. A client who has anemia, hemoglobin of 11 g/dL, and is prescribed epoetin alfa

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because a client who is post-CABG and has high cholesterol is not in immediate danger, as atorvastatin is a long-term medication that lowers cholesterol and prevents cardiovascular complications.

Choice B Reason: This is incorrect because a client who has pneumonia and a slightly elevated WBC count is not in immediate danger, as piperacillin is an antibiotic that treats bacterial infections.

Choice C Reason: This is correct because a client who has renal failure and a high serum potassium level is in immediate danger, as sodium polystyrene sulfonate is an emergency medication that lowers potassium and prevents cardiac arrhythmias.

Choice D Reason: This is incorrect because a client who has anemia and a mild hemoglobin deficiency is not in immediate danger, as epoetin alfa is a long-term medication that stimulates red blood cell production and improves oxygen delivery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["24"]

Explanation

A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first?

Correct Answer is C

Explanation

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