An adult with head and facial injuries from a motor vehicle collision is fully immobilized and has a Glasgow coma score of 6. The client is intubated, sedated, and is being prepared for transfer to a regional trauma center. Which intervention(s) should the nurse implement? Select all that apply.

Allow the family to touch and talk to the client.

Reassess the client's vascular access.

Assess neurological vital signs every 15 minutes.

Administer ophthalmic ointment.

Apply soft bilateral wrist restraints for transport.

Answer and Explanation

Correct Answer : A,B,C,D

A. Allow the family to touch and talk to the client. Family presence can provide emotional support for both the client and loved ones. Even though the client is sedated and has a low GCS, familiar voices and touch may reduce stress and anxiety. Allowing family interaction fosters comfort and connection during a critical time.
B. Reassess the client's vascular access. Maintaining secure and functional vascular access is essential for administering fluids, medications, and emergency interventions. Before transport, the nurse should confirm IV patency, ensure secure connections, and assess for signs of infiltration or malfunction. Trauma patients may require additional or larger bore IV access for fluid resuscitation or transfusion.
C. Assess neurological vital signs every 15 minutes. Frequent neurological assessments are crucial in head trauma patients with a low GCS to monitor for signs of worsening intracranial pressure, cerebral edema, or herniation. Changes in pupil response, motor function, or vital signs may indicate neurological deterioration requiring urgent intervention. Monitoring trends over time is necessary for early detection of complications.
D. Administer ophthalmic ointment. Clients with a low GCS often have impaired blinking, placing them at risk for corneal abrasions and dryness. Applying ophthalmic lubricant or artificial tears protects the cornea from injury and promotes eye health. Preventing exposure keratitis is essential in unconscious or sedated clients to avoid long-term ocular damage.
E. Apply soft bilateral wrist restraints for transport. Restraints are unnecessary because the client is sedated, intubated, and has a GCS of 6, meaning they cannot attempt self-extubation or interfere with care. Restraints should only be used if the client demonstrates a risk of harm. Standard transport protocols prioritize sedation and safety measures over restraints unless specifically required.

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Correct Answer is A

Explanation

A. Normal sinus rhythm (NSR) at 84 beats/minute. The goal of cardioversion for atrial fibrillation (AFib) is to restore a normal sinus rhythm (NSR). NSR indicates that the atria and ventricles are depolarizing in a coordinated manner, reducing the risk of thromboembolism, stroke, and hemodynamic instability. A heart rate of 84 beats/minute is within the normal range, confirming the success of the procedure.
B. Regular rhythm with consistent pacemaker capture. Cardioversion is used to restore normal rhythm in AFib, not to manage pacemaker function. A pacemaker is not part of standard AFib cardioversion unless the client has underlying conduction issues requiring pacing.
C. Return of elevated ST segment to the baseline. ST elevation suggests acute myocardial infarction (MI), which is unrelated to atrial fibrillation or cardioversion. Cardioversion does not treat ST elevation or myocardial ischemia, making this an incorrect indicator of success.
D. Increased frequency of QRS complexes. An increase in QRS frequency suggests tachycardia, which would indicate treatment failure rather than success. The goal of cardioversion is to restore a normal, controlled heart rate and rhythm, not to increase the number of ventricular contractions.

A. Heparin is infused in less than four hours. B. Systolic blood pressure greater than 120 mm Hg. C. No knee pain upon forced dorsiflexion. D. Intra-arterial cannula remains patent.

Correct Answer is D

Explanation

A. Heparin is infused in less than four hours. The heparinized solution used in an intra-arterial (IA) pressure infuser is not intended for systemic anticoagulation but rather to maintain catheter patency. The infusion rate is typically slow and continuous, and completing the infusion in less than four hours is not an indicator of effectiveness.
B. Systolic blood pressure greater than 120 mm Hg. Heparin in an IA pressure infuser does not directly affect blood pressure. Its purpose is to prevent clot formation within the catheter, ensuring uninterrupted arterial pressure monitoring. BP readings are monitored separately and are not an indicator of heparin’s therapeutic effect.
C. No knee pain upon forced dorsiflexion. This assessment is used to evaluate deep vein thrombosis (DVT) (Homan's sign), which is not related to arterial catheter function. The low-dose heparin in the pressure infuser does not provide systemic anticoagulation, making this finding irrelevant.
D. Intra-arterial cannula remains patent. The primary purpose of heparinized flush solutions in IA lines is to prevent clot formation within the catheter and maintain patency for continuous blood pressure monitoring or arterial blood sampling. A patent arterial line confirms that the heparin infusion is achieving its intended effect.

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An adult with head and facial injuries from a motor vehicle collision is fully immobilized and has a Glasgow coma score of 6. The client is intubated, sedated, and is being prepared for transfer to a regional trauma center. Which intervention(s) should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A client has been treated for uncontrolled atrial fibrillation with cardioversion. Following the cardioversion, which assessment finding indicates to the nurse that the desired outcome was achieved?

Correct Answer is A

Explanation

A postoperative client is admitted to the intensive care unit (ICU) with an inflated pressure infuser containing a solution of heparin 2 units/ml attached to an intra-arterial (IA) cannula. Which finding indicates that the heparin infusion has achieved its therapeutic use?

Correct Answer is D

Explanation

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