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 B

Explanation

A. Check the tubing connections for leaks. is incorrect. Slow, steady bubbling in the suction control chamber is normal if suction is correctly set up.

B. Check the suction control outlet on the wall. is correct. If there is slow, steady bubbling, it may indicate that the suction control pressure needs adjustment.

C. Continue to monitor the client's respiratory status. is incorrect. While monitoring is always important, it does not address the issue of the bubbling in the suction control chamber.

D. Clamp the chest tube. is incorrect. Clamping the chest tube is not appropriate and can lead to complications.

A. "The footplate keeps the client from sliding down in bed." B. "The footplate helps to prevent foot drop." C. "The footplate works to anchor the traction." D. "The footplate prevents pressure sores on the heel."

Correct Answer is B

Explanation

A. The footplate keeps the client from sliding down in bed is not the primary function of the footplate in Buck’s traction.

B. The footplate helps to prevent foot drop by maintaining proper alignment of the foot and leg in Buck’s traction.

C. The footplate works to anchor the traction is incorrect; traction is anchored by weights and pulleys, not the footplate.

D. The footplate prevents pressure sores on the heel is not the primary purpose of the footplate in Buck's traction.

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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?

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Naxlex Comprehensive Predictor Exams

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