The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

T 92.5 F (33.6 C), BP 90/64, HR 80, RR 14, 02 Sat 97% Room Air

T 98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air

T 98.6 F (37 C), BP 200/94, HR 90, RR 18, 02 Sat 100% Room Air

T 103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air

Answer and Explanation

The Correct Answer is B

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

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Free Nursing Study Resources

Correct Answer is ["16"]

Explanation

To calculate the dosage of Vancomycin, first convert the patient's weight from pounds to kilograms, knowing that 1 kg equals 2.2 lbs. The patient weighs 110 lbs, which is equivalent to 50 kg (110 lbs / 2.2). Next, multiply the patient's weight in kilograms by the prescribed dosage of 20 mg/kg, resulting in a total dosage of 1000 mg (50 kg * 20 mg/kg). Since the vials contain 500 mg per 8 mL, divide the total dosage required by the amount per vial to find out how many milliliters should be withdrawn. This results in 16 mL (1000 mg / (500 mg/8 mL)).

A. Place soft restraints on the patient B. Place a padded tongue blade in the client's mouth C. Turn the patient on the side and stay with them D. Immediately go to the nurses' station for help E. Respirations

Correct Answer is C

Explanation

A. Soft restraints are not recommended during a seizure and can cause harm to the patient.

B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.

C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.

D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.

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The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

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Naxlex Comprehensive Predictor Exams

A physician prescribes Vancomycin 20 mg/kg intravenous (IV). The patient weighs 110 lbs. The medication is available in vials which contain 500 mg per 8 mL. What should the nurse withdraw from the vial? (round to the nearest whole number)

Correct Answer is ["16"]

Explanation

The nurse is performing the morning assessment on a patient. The patient suddenly screams loudly and begins to have a generalized tonic/clonic type seizure. What is the priority nursing intervention?

Correct Answer is C

Explanation

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