A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

Use log rolling to reposition the client.

Place a warming blanket on the client.

Instruct the client to cough and deep breathe.

Place the client in a supine position.

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is correct because using log rolling to reposition the client helps maintain the alignment of the head and neck, which prevents further increases in ICP.

Choice B Reason: This is incorrect because placing a warming blanket on the client can cause vasodilation and increase cerebral blood ﬂow, which can raise ICP.

Choice C Reason: This is incorrect because instructing the client to cough and deep breathe can increase intrathoracic pressure and impede venous return, which can elevate ICP.

Choice D Reason: This is incorrect because placing the client in a supine position can decrease cerebral perfusion pressure and increase ICP. The client should be placed in a semi-Fowler's position with the head elevated at 30 degrees.

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Correct Answer is B

Explanation

Choice A Reason: This choice is incorrect because hypomagnesemia is not a common finding in the oliguric phase of acute kidney injury. Hypomagnesemia is a condition in which the serum magnesium level is lower than normal (less than 1.5 mEq/L). It may be caused by various factors such as malnutrition, diarrhea, diuretics, or alcohol abuse. It may cause symptoms such as muscle weakness, tremors, tetany, or cardiac arrhythmias.

Choice B Reason: This choice is correct because hyperkalemia is a common finding in the oliguric phase of acute kidney injury. Hyperkalemia is a condition in which the serum potassium level is higher than normal (more than 5 mEq/L). It may be caused by reduced renal excretion of potassium due to decreased urine output (oliguria). It may cause symptoms such as muscle weakness, paresthesia, bradycardia, or cardiac arrest.

Choice C Reason: This choice is incorrect because decreased creatinine level is not a common finding in the oliguric phase of acute kidney injury. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys and excreted in urine. A normal creatinine level ranges from 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women. In acute kidney injury, creatinine level usually increases due to reduced renal function and impaired clearance of creatinine.

Choice D Reason: This choice is incorrect because increased glomerular filtration rate (GFR) is not a common finding in the oliguric phase of acute kidney injury. GFR is a measure of how well

the kidneys filter blood and remove waste products.

A normal GFR range is 90,to 120 mL/min/1.73 m2. In acute kidney injury, GFR usually decreases due to reduced blood ﬂow,to,the kidneys or damage to the glomeruli, which are the tiny blood vessels that filter blood in the kidneys.

Correct Answer is ["100"]

Explanation

To estimate the percentage of body surface area burned using the Rule of Nines, follow these guidelines:

Head and Neck: 9%
Each Arm: 9% (right arm) + 9% (left arm) = 18%
Front of Torso: 18%
Back of Torso: 18%
Each Leg: 18% (right leg) + 18% (left leg) = 36%
Genital Area: 1%

Now, add up the percentages of the burned areas:

9% (head and neck) + 18% (each arm) + 18% (front of torso) + 18% (back of torso) + 36% (each leg) + 1% (genital area) = 100%

So, the nurse should estimate that the client has burned 100% of their body surface area.

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A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

Correct Answer is ["100"]

Explanation

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