The nurse is caring for a client who sustained a moderate head injury following a bicycle accident.
The nurse's most recent assessment reveals that the client's respiratory effort has increased.
What is the nurse's most appropriate action?
Administer a bolus of normal saline as prescribed.
Administer bronchodilators as prescribed and monitor the client's LOC.
Increase the client's bed height and reassess in 30 minutes.
Inform the care team and assess for further signs of possible increased ICP.
The Correct Answer is D
Choice A rationale
Administering a bolus of normal saline may not directly address the cause of increased respiratory effort, which could be related to increased intracranial pressure (ICP). Normal saline administration is not the priority intervention in this case.
Choice B rationale
Bronchodilators are used to manage bronchoconstriction, not increased respiratory effort due to potential increased ICP. Monitoring the client's level of consciousness (LOC) is important, but bronchodilators are not indicated here.
Choice C rationale
Increasing the client's bed height can help with respiratory effort, but it does not directly address the potential underlying issue of increased ICP. Reassessing in 30 minutes might delay necessary interventions.
Choice D rationale
Increased respiratory effort in a client with a head injury may indicate rising ICP. Informing the care team and assessing for further signs of increased ICP is crucial for timely intervention to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Aspiration of synovial fluid for serologic testing is a procedure known as arthrocentesis, which involves extracting joint fluid for analysis. While useful for diagnosing conditions like infections or arthritis, it is not the same as arthrography, which involves imaging.
Choice B rationale
Injection of corticosteroids into the client's knee joint to facilitate ROM is a therapeutic procedure to reduce inflammation and improve movement in conditions like arthritis, but it is not part of an arthrography procedure.
Choice C rationale
Injection of a contrast agent into the knee joint prior to ROM exercises is a key part of arthrography. The contrast agent helps to enhance the imaging of the joint structures during movement, allowing for a detailed assessment of the joint.
Choice D rationale
Replacement of the client's synovial fluid with a synthetic substitute is not related to arthrography. This description aligns more with viscosupplementation, a treatment for osteoarthritis.
Correct Answer is D
Explanation
Choice A rationale
Techniques for performing neck ROM exercises might be relevant but are secondary to the immediate postoperative care following a cervical discectomy.
Choice B rationale
Restoring nerve function is a goal but not directly linked to discharge education strategies after cervical discectomy.
Choice C rationale
Home assessment of ABGs is not relevant to discharge education for a cervical discectomy, as it pertains more to respiratory status monitoring.
Choice D rationale
Care of the cervical collar is essential post-discectomy as it provides stability, reduces strain on the cervical spine, and supports the healing process, making it a critical part of discharge education.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.