An intubated client with increased intracranial pressure has pooled secretions in the airway.
Which action should the nurse take first?

Elevate the head of the bed.

Limit stimulation.

Suction the airway.

Administer a sedative.

Answer and Explanation

The Correct Answer is C

Maintaining airway patency while managing intracranial pressure requires a balance between oxygenation and avoiding spikes in pressure. Knowledge of airway management and the physiological effects of hypoxia on cerebral edema is essential for prioritizing immediate life-saving interventions.

Choice A rationale

Elevating the head of the bed to 30 to 45 degrees promotes venous drainage and reduces intracranial pressure. While a standard nursing intervention for these patients, it does not clear an obstructed airway caused by pooled secretions.

Choice B rationale

Limiting stimulation helps prevent sudden increases in intracranial pressure caused by environmental stress. Although important for neurological stability, it is not the priority when the client's airway is compromised by secretions that prevent adequate ventilation.

Choice C rationale

Suctioning is necessary to clear the airway and maintain oxygenation. Hypoxia and hypercapnia are potent vasodilators that significantly increase intracranial pressure. Clearing the airway is the first priority, though it should be done quickly to minimize stimulation.

Choice D rationale

Sedatives may be used to reduce metabolic demand and blunt the intracranial pressure response to noxious stimuli like suctioning. However, administration takes time and does not physically remove the secretions causing the immediate airway obstruction..

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Acute neurological deficits following a stroke increase the risk of secondary complications. Knowledge of cranial nerve involvement and protective reflexes is vital. The nurse must prioritize airway and respiratory safety within the critical 24 hour post ischemic event window.

Choice A rationale

Right sided weakness often includes the facial and pharyngeal muscles, impairing the gag reflex and swallowing. This increases the risk of food or secretions entering the lungs, leading to pneumonia or acute respiratory distress during recovery.

Choice B rationale

While urinary retention can occur after a stroke due to neurogenic bladder or immobility, it is not an immediate life threat. It requires monitoring and management but takes lower priority than ensuring the client maintains a patent airway.

Choice C rationale

Contractures are a long term complication of immobility and muscle spasticity following a stroke. While range of motion exercises are important for rehabilitation, they are not a priority during the first 24 hours of acute stabilization.

Choice D rationale

Depression is a common psychological consequence of the lifestyle changes and deficits caused by a stroke. However, psychological assessment occurs later in the care plan after the client is physiologically stable and out of danger.

A. Magnesium. B. Sodium bicarbonate. C. Atropine. D. Epinephrine.

Correct Answer is C

Explanation

This scenario requires applying advanced cardiac life support protocols for post-arrest arrhythmias. Knowledge of autonomic nervous system pharmacology is essential to identify the specific medication that increases heart rate by blocking parasympathetic vagal inhibition on the sinoatrial node during symptomatic bradycardia.

Choice A rationale

Magnesium sulfate is primarily utilized to treat torsades de pointes or hypomagnesemia. It acts as a calcium channel blocker in myocardial cells but does not specifically increase heart rate for bradycardia when normal sinus rhythm has already been restored.

Choice B rationale

Sodium bicarbonate is administered to treat specific metabolic acidosis or certain drug toxicities during prolonged arrest. It does not possess chronotropic properties and will not increase the heart rate in a client suffering from a symptomatic slow rhythm.

Choice C rationale

Atropine is an anticholinergic drug that inhibits the vagus nerve, effectively increasing the firing rate of the sinoatrial node. It is the first-line medication for symptomatic bradycardia to improve cardiac output and maintain adequate systemic tissue perfusion.

Choice D rationale

Epinephrine is a potent vasopressor and inotrope used primarily during active pulseless arrest. While it increases heart rate, atropine is specifically indicated first for a restored rhythm that remains slow and symptomatic before progressing to more powerful infusions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An intubated client with increased intracranial pressure has pooled secretions in the airway. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with an ischemic stroke has right-sided weakness and slurred speech. Which complication should the nurse prioritize monitoring for in the first 24 hours?

Correct Answer is A

Explanation

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?

Correct Answer is C

Explanation

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

A nurse is reviewing the plan of care for a client who is currently admitted to a medical surgical unit. Which intervention should the nurse include to promote patient safety and prevent falls?

A client with cirrhosis and severe ascites is scheduled for a paracentesis. Post-procedure, the client develops signs of tachycardia, hypotension, and mild fever. Which conditions could cause these symptoms? Select all that apply.

The nurse reviews laboratory results for a client with disseminated intravascular coagulation who is being monitored for complications related to abnormal clotting. Which findings would most suggest the development of organ dysfunction secondary to thrombotic microangiopathy?

A client is admitted to the emergency department following a motor vehicle accident. Which nursing actions should the nurse take during the primary survey?

A client with cancer develops signs of confusion, headache, and visual disturbances. The nurse suspects superior vena cava syndrome. Which symptoms support the nurse's suspicion? Select all that apply.

A client in the rehabilitative phase of a burn injury has healed graft sites and is beginning mobility exercises. Which intervention is most important to minimize scarring and promote functional recovery?

An intubated client with increased intracranial pressure has pooled secretions in the airway.
Which action should the nurse take first?