Here is the edited text:
A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?

Administer a vasodilator medication.

Elevate the head of the bed to 30°.

Apply a cold compress to the forehead.

Decrease the oxygen ﬂow rate.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This choice is incorrect because administering a vasodilator medication may lower the blood pressure and worsen the cerebral perfusion. A vasodilator medication is a drug that relaxes the blood vessels and reduces the resistance to blood ﬂow. It may be used for clients who have hypertension, angina, or heart failure, but it does not help to reduce the intracranial pressure (ICP).

Choice B Reason: This choice is correct because elevating the head of the bed to 30° may help to improve the venous drainage and decrease the ICP. ICP is the pressure exerted by the brain tissue, cerebrospinal ﬂuid (CSF), and blood within the cranial cavity. A normal ICP range is 5 to 15 mm Hg, and an elevated ICP (>20 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, positioning the client in a semi-Fowler's position (30° angle) or high- Fowler's position (60° to 90° angle) can facilitate breathing and prevent further complications.

Choice C Reason: This choice is incorrect because applying a cold compress to the forehead may cause vasoconstriction and increase the ICP. A cold compress is a device that applies cold temperature to a body part to reduce inﬂammation, pain, or swelling. It may be used for clients who have headaches, sprains, or bruises, but it does not help to reduce the ICP.

Choice D Reason: This choice is incorrect because decreasing the oxygen ﬂow rate may cause hypoxia and worsen the cerebral ischemia. Hypoxia is a condition in which the body or a part of it does not receive enough oxygen. It may cause symptoms such as confusion, agitation, or cyanosis. Therefore, providing adequate oxygenation and ventilation is essential to maintain the brain function and prevent further damage.

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Correct Answer is B

Explanation

Choice A Reason: This choice is incorrect because oral hypoglycemic medications are not eﬀective for treating DKA. Oral hypoglycemic medications are drugs that lower the blood glucose level by stimulating insulin secretion or increasing insulin sensitivity. They may be used for clients who have type 2 diabetes mellitus, but they do not work for clients who have type 1 diabetes mellitus or DKA.

Choice B Reason: This choice is correct because 0.9% sodium chloride IV bolus is an eﬀective treatment for DKA. 0.9% sodium chloride is an isotonic solution that contains the same concentration of solutes as blood plasma. It may be used for clients who have ﬂuid loss, dehydration, or shock. In DKA, the body breaks down fat for energy due to insulin deficiency or resistance, resulting in high levels of ketones and acids in the blood. This causes osmotic diuresis, dehydration, electrolyte imbalance, and metabolic acidosis. Therefore, administering 0.9% sodium chloride IV bolus can help to restore ﬂuid volume and correct electrolyte imbalance.

Choice C Reason: This choice is incorrect because dextrose 5% in 0.45% sodium chloride is not indicated for treating DKA. Dextrose 5% in 0.45% sodium chloride is a hypertonic solution that contains more solutes than blood plasma. It may be used for clients who have hyponatremia, cerebral edema, or malnutrition, but it can worsen hyperglycemia and osmotic diuresis in clients who have DKA.

Choice D Reason: This choice is incorrect because glucocorticoid medications are not indicated for treating DKA. Glucocorticoid medications are drugs that mimic the eﬀects of cortisol, a hormone that regulates stress response and inﬂammation. They may be used for clients who have allergic reactions, asthma, or autoimmune diseases, but they can increase blood glucose levels and inhibit insulin action in clients who have DKA.

A. Dextrose 5% in 0.9% sodium chloride B. Dextrose 5% in water C. 0.9% sodium chloride D. Lactated Ringer's

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can cause ﬂuid overload and pulmonary edema in a client who has burns.

Choice B Reason: This is incorrect because dextrose 5% in water is a hypotonic solution that can cause ﬂuid shifts from the intravascular space to the interstitial space, resulting in hypovolemia and hypotension in a client who has burns.

Choice C Reason: This is incorrect because 0.9% sodium chloride is an isotonic solution that can cause hypernatremia and hyperchloremia in a client who has burns, as the ﬂuid loss from burns is greater than the sodium loss.

Choice D Reason: This is correct because lactated Ringer's is an isotonic solution that contains electrolytes similar to plasma, such as sodium, potassium, calcium, and chloride. It also contains lactate, which is converted to bicarbonate in the liver and helps correct the metabolic acidosis that occurs in a client who has burns.

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Here is the edited text: A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?

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Here is the edited text:
A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?