A nurse is caring for a client who is experiencing Cushing's triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

Albumin 25%

Dextran 70

Mannitol 25%

Hydroxyethyl starch

Answer and Explanation

The Correct Answer is C

Choice A Reason: Albumin 25% is not a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Albumin 25% is a colloid solution that increases the oncotic pressure and draws ﬂuid from the interstitial space into the intravascular space, which can worsen the intracranial pressure by increasing the cerebral blood ﬂow and edema.

Choice B Reason: Dextran 70 is not a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Dextran 70 is a plasma expander that increases the blood volume and viscosity, which can also worsen the intracranial pressure by increasing the cerebral blood ﬂow and edema.

Choice C Reason: Mannitol 25% is a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Mannitol 25% is an osmotic diuretic that reduces the intracranial pressure by creating an osmotic gradient and drawing ﬂuid from the brain tissue into the blood vessels, which can then be excreted by the kidneys. The nurse should monitor the urine output, serum osmolality, and electrolytes when administering mannitol 25%.

Choice D Reason: Hydroxyethyl starch is not a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Hydroxyethyl starch is another plasma expander that has similar eﬀects as dextran 70, and can also increase the risk of coagulopathy and renal failure.

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Correct Answer is D

Explanation

Choice A Reason: This choice is incorrect because ﬂatened neck veins are not a sign of cardiac tamponade. Cardiac tamponade is a condition in which ﬂuid accumulates in the pericardial sac that surrounds the heart, causing compression and impaired filling of the heart chambers. This leads to reduced cardiac output and hypotension. One of the manifestations of cardiac tamponade is distended neck veins due to increased venous pressure and impaired venous return.

Choice B Reason: This choice is incorrect because bradycardia is not a sign of cardiac tamponade. Bradycardia is a condition in which the heart rate is slower than normal (less than 60 beats per minute). It may be caused by various factors such as vagal stimulation, medication side eﬀects, hypothyroidism, or sinus node dysfunction. It may cause symptoms such as fatigue, dizziness, or syncope, but it does not indicate cardiac tamponade.

Choice C Reason: This choice is incorrect because sudden lethargy is not a specific sign of cardiac tamponade. Lethargy is a condition in which the person feels tired, sluggish, or drowsy. It may be caused by various factors such as sleep deprivation, depression, infection, anemia, or hypoglycemia. It may aﬀect the person's mental and physical performance, but it does not indicate cardiac tamponade.

Choice D Reason: This choice is correct because muﬄed heart sounds are a sign of cardiac tamponade. Muﬄed heart sounds are heart sounds that are fainter or softer than normal due to reduced transmission of sound waves through ﬂuid-filled pericardial sac. They may indicate that the heart function is compromised by cardiac tamponade and require immediate intervention such as pericardiocentesis (removal of ﬂuid from pericardial sac).

A. 54 percent B. 36 percent C. 18 percent D. 9 percent

Correct Answer is A

Explanation

Choice A Reason: To calculate the total body surface area (TBSA) affected by burns using the Rule of Nines, the body is divided into sections, each representing a percentage of TBSA:

Front of one leg = 9%
Back of one leg = 9%
Front of one arm = 4.5%
Back of one arm = 4.5%

Now for the calculation:

Both legs (front and back):
- Front of both legs = 9% × 2 = 18%
- Back of both legs = 9% × 2 = 18%
- Total for both legs = 18% + 18% = 36%
Both arms (front and back):
- Front of both arms = 4.5% × 2 = 9%
- Back of both arms = 4.5% × 2 = 9%
- Total for both arms = 9% + 9% = 18%
Total TBSA:
- Legs (36%) + Arms (18%) = 54%

The nurse should document burns to 54% of the client's total body surface area (TBSA).

Choice B Reason:This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.

Choice C Reason: This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.

Choice D Reason: This choice is incorrect because it uses a random percentage that does not correspond to any rule or calculation.

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A nurse is caring for a client who is experiencing Cushing's triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

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Naxlex Comprehensive Predictor Exams

A nurse in a critical care unit is caring for a client who suﬀered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Correct Answer is D

Explanation

A nurse in an emergency department is caring for an adult client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

Correct Answer is A

Explanation

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