When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?
Check the equipment.
Continue the assessment because no actions are indicated at this time.
Document the reading because it reflects that the treatment has been effective.
Contact the health care provider to review the care plan.
The Correct Answer is A
Choice A rationale
The nurse should check the equipment first when an ICP reading of 0 mm Hg is noted, as this may indicate equipment malfunction. An accurate ICP reading is critical for assessing and managing intracranial pressure to ensure the client's safety.
Choice B rationale
Continuing the assessment without checking the equipment may lead to incorrect conclusions based on a potentially faulty reading. It’s crucial to ensure the accuracy of the equipment before proceeding.
Choice C rationale
Documenting the reading as an effective treatment outcome without verifying its accuracy can be dangerous. An ICP reading of 0 mm Hg is unusual and warrants equipment verification.
Choice D rationale
Contacting the health care provider to review the care plan is premature until the equipment has been checked to rule out a false reading, ensuring the nurse provides accurate information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A cerebral perfusion pressure (CPP) of 40 mm Hg is considered low, as the normal range for CPP is typically between 60 and 80 mm Hg. Low CPP can lead to inadequate blood flow to the brain.
Choice B rationale
An accurate CPP reading is crucial for assessing intracranial pressure and cerebral blood flow. A reading of 40 mm Hg is not typically considered inaccurate.
Choice C rationale
A CPP of 40 mm Hg is not within normal limits, as it is significantly below the normal range.
Choice D rationale
A CPP of 40 mm Hg is not high; it is considered low and requires medical attention.
Correct Answer is D
Explanation
Choice A rationale
Infection is not directly related to weight loss, ill-fitting dentures, or limited fiber intake. The primary risks are more connected to gastrointestinal function rather than infections. While malnutrition can affect immune response, infection risk isn’t the primary concern here.
Choice B rationale
Deficient fluid volume is not a direct consequence of weight loss or dietary habits related to ill-fitting dentures. While fluid intake should be monitored, it is not the most immediate risk associated with these symptoms.
Choice C rationale
Excessive intake of convenience foods might contribute to poor nutritional status and unintended weight loss, but it is not the primary risk. The client's condition more directly influences gastrointestinal health rather than dietary habits.
Choice D rationale
Constipation is a significant risk due to limited intake of high-fiber foods. Fiber is crucial for promoting bowel movements and preventing constipation. Weight loss and ill-fitting dentures may further reduce the client's dietary fiber intake, increasing the likelihood of constipation
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