The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?
Suction the patient to minimize secretions
Continue with the assessment and document the finding
Notify the physician and raise HOB to 35-45 degrees
Lower the head of the bed and pad the side rails
The Correct Answer is C
A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.
B. Documenting without intervention could lead to worsening of the patient's condition.
C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.
D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.
B. Documenting without intervention could lead to worsening of the patient's condition.
C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.
D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.
Correct Answer is A
Explanation
A. A pH within the normal range, a PaCO2 within the normal range, and an improved PaO2 level suggest effective treatment for an asthma attack, indicating adequate gas exchange and resolution of respiratory distress.
B. A pH of 7.52 and low PaCO2 suggest respiratory alkalosis, which can occur with hyperventilation and may indicate overventilation rather than effective asthma treatment.
C. This result shows elevated PaCO2 and borderline low PaO2, indicating ongoing respiratory acidosis and hypoxia, suggesting the treatment is not yet effective.
D. This ABG result shows low pH, indicating acidosis, and a low bicarbonate level, which may indicate metabolic acidosis rather than effective asthma management.
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