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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Given:
- IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline.
- The prescribed rate is 8 units/hr.
First, we find out how many units are present in 1 mL of the IV solution:
100 units / 100 mL = 1 unit / 1 mL
Now, since the prescribed rate is 8 units/hr, we need to infuse 8 mL/hr of the IV solution to deliver 8 units of insulin per hour.
So, the nurse should program the infusion pump to deliver 8 mL/hr.
Correct Answer is ["100"]
Explanation
- First, determine the total volume to be infused: 50 mL.
- Next, calculate the time in hours: 30 minutes is 0.5 hours.
50/0.5
= 100mL/hr
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