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 is incorrect because crepitus in the area above and surrounding the insertion site is not a serious finding that requires notification of the provider. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It is usually harmless and resolves on its own.

Choice B reason: This is incorrect because bubbling of the water in the water seal chamber with exhalation is a normal finding that indicates that air is being removed from the pleural space. Bubbling should stop when the pneumothorax is resolved.

Choice C Reason: This is incorrect because eyelets are not visible is not a serious finding that requires notification of the provider. Eyelets are small holes at the end of the chest tube that allow air and ﬂuid to drain from the pleural space. They are usually covered by a dressing and may not be visible.

Choice D Reason: This is correct because movement of the trachea toward the unaﬀected side is a serious finding that indicates a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and causes pressure on the mediastinum. The nurse should notify the provider immediately and prepare for needle decompression or chest tube insertion.

A. The client is unconscious. B. The client can follow simple motor commands. C. The client is unable to make vocal sounds. D. The client opens his eyes when spoken to.

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because the client is not unconscious, as the GCS score ranges from 3 to 15, with 3 being the lowest possible score and indicating deep coma or death.

Choice B Reason: This is correct because the client can follow simple motor commands, as the GCS score for best motor response is 5, which means the client can localize pain by moving his limbs away from the source of stimulation.To interpret the Glasgow Coma Scale (GCS) score provided in the scenario:Eye Opening (E): 3 - The client opens their eyes in response to verbal stimuli.Best Verbal Response (V): 5 - The client is oriented and able to engage in coherent conversation.Best Motor Response (M): 5 - The client can localize pain or follow motor commands (depending on additional context). The total GCS score would be 3 + 5 + 5 = 13, indicating a mild level of impairment or responsiveness.

Choice C Reason: This is incorrect because the client is able to make vocal sounds, as the GCS score for best verbal response is 5, which means the client can orient himself to person, place, and time.

Choice D Reason: This is incorrect because the client does not open his eyes when spoken to, as the GCS score for eye opening is 3, which means the client only opens his eyes in response to pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is D

Explanation

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is B

Explanation

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