A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?

Flex the client's hip.

Hyperextend the client's neck.

Provide warming measures for the client.

Adjust the client's head of bed.

Answer and Explanation

The Correct Answer is D

A. Flex the client’s hip is incorrect. Flexing the hip can increase intra-abdominal pressure and potentially increase intracranial pressure.

B. Hyperextend the client’s neck is incorrect. Hyperextension of the neck can interfere with venous return from the brain and increase ICP.

C. Provide warming measures for the client is incorrect. Warming measures are not indicated for a low CPP; maintaining normothermia is important, but warming is not the priority action.

D. Adjust the client’s head of bed is correct. Elevating the head of the bed helps reduce ICP and improves cerebral perfusion by promoting venous outflow.

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Correct Answer is C

Explanation

A. The side-lying position is not appropriate for paracentesis because it does not allow optimal access to the abdomen and can make fluid removal more difficult.

B. The supine position is also not suitable for paracentesis, as it may not allow for proper drainage and can increase the risk of respiratory compromise, especially in clients with large volumes of ascitic fluid.

C. High-Fowler’s position is correct because it helps pool the ascitic fluid in the lower abdomen, making it easier to access and drain during the procedure. This position also helps improve breathing by relieving pressure on the diaphragm caused by the ascites.

D. The leaning forward position is not appropriate for paracentesis, as it can be uncomfortable and does not provide optimal access to the abdominal cavity for fluid removal.

A. Blockage of the ET tube by the client's tongue B. Movement of the ET tube into the right main bronchus C. Infection of the vocal cords D. Passage of the ET tube into the esophagus

Correct Answer is B

Explanation

A. Blockage of the ET tube by the client's tongue would not typically result in asymmetric chest wall expansion.
B. If the ET tube has moved into the right main bronchus, it will cause more air to enter the right lung and less to the left, leading to decreased left-sided chest wall expansion.
C. Infection of the vocal cords is not related to the absence of chest wall expansion.
D. Passage of the ET tube into the esophagus would lead to the absence of breath sounds in both lungs, not just the left side.

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A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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