S14

The nurse assess a patient with a skull fracture and notes a Glasgow coma scale score of 3. Additional vital signs assessed by the nurse include Bp 100/70 mm Hg, heart rate 55 beats/ min, RR 10 breaths/min, O2 94% on oxygen at 3L per nasal cannula. What is the priority nursing action? A. Monitor the patients airway potency B. Elevate the head of the patients bed C. Increase supplemental oxygen delivery D. Support bony prominences with padding

A

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy the nurse assesses the following vital signs. Blood pressure 100/60 mm Hg, HR 52 bpm, RR 24, O2 saturation. 97% on supplemental oxygen at 45% via venturi mask, Glasgow coma scale score of 4 and intracranial pressure (ICP) of 18 mm Hg. Which order should the nurse institute first? A. Mannitol 1 g intravenous B. Portable chest X-ray C. Seizure precautions D. Ancef 1 g intravenous

A

The nurse responds to a high heart rate alarm for a patient in the neurological ICU. The nurse arrives to find the patient sitting in a chair experiencing a tonic clonic seizure. What is the best nursing action? A. Assist the patient to the floor and provide soft head support. B. Insert a nasogastric tube and connect C. Open the patients mouth and insert a padded tongue blade D. Restrain the patients extremities until the seizure subsides.

A

In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing if this reflex are true (SATA) A. Doll eyes absent indicate a disruption in normal brain stem processing B. Doll eyes present indicate brain stem activity C. Eye movement in the opposite direction as the head when turned indicates an intact reflex. D. Eye movement in the same direction as the head when turned indicates an intact reflex E. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex F. Presence of cervical injuries is a contraindication to the assessment of this reflex

A B C E F

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients what is the best action by the nurse. A. Implement droplet precautions upon admission B. Wash hands thoroughly before leaving the room C. Scrub the hub of all central line ports prior to use D. Dispose of all bloody dressings in biohazard bags

A

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of intracranial bleed. Which actions are most important to include in the patients plan of care. (SATA) A. Make frequent neurological assessments B. Maintain CO2 level at 50 mm Hg C. Maintain MAP less than 130 mm Hg D. Prepare for thrombolytic administration E. Restrain affected limb to prevent injury

A C

The nurse is preparing to administer a routine dose of phenytoin. The primary care provider orders phenytoin 500 mg, intravenously q 6 hours. What s the best action by the nurse? A. Administer over 2 minutes B. Administer with 0.9% normal saline intravenous C. Contact the primary care provider to discuss the order D. Assess cardiac rhythm

C

While caring for a patient with traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse. A. Both pressures are high B. Both pressures are low C. ICP is high; cpp is normal D. ICP is high; CPP is low

C

The nurse is preparing to monitor intracranial pressure with a fluid filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring (SATA) A. Use of a heparin flush solution B. Manually flushing the device prn C. Recording ICP as a "mean" value D. Use of a pressurized flush system E. Zero referencing the transducer system

C E

After receiving the hand off report from the day shift charge nurse, which patient should the evening charge nurse assess first. A. A patient with meningitis complaining of photophobia B. A mechanically ventilated patient with a GCS of 6 C. A patient with bacterial meningitis on droplet precautions D. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F

D

The nurse admits a patient to the emergency department with new onset of slurred speech and right sided weakness. What is the priority nursing action to assure effective care? A. Assess for the presence of a headache B. Assess the patients general orientation C. Determine the patients drug allergies D. Determine the time of symptom onset

D

The nurse is caring for a patient with an intracranial pressure ICP of 18mm Hg and a GCS score of 3. Following the administration of mannitol, which assessment finding by the nurse requires further action? A. ICP of 10 mm Hg B. CPP of 70 mm Hg C. GCS score of 5 D. CVP of 2 mm Hg

D

While caring for a patient with a closed head injury, the nurse assess the patient be alert with a blood pressure of 130/90 mm Hg, heart rate 60 beats/ min, RR 18 breaths/min and temp of 102 F. To reduce risk of increased intracranial pressure (ICP) in this patient what are the priority nursing actions? A. Ensure adequate periods of rest between nursing interventions B. Insert an oral airway and monitor respiratory rate and depth C. Maintain neutral head alignment and avoid extreme hip flexion D. Reduce ambient room temperature and administer antipyretics

D

A patient with a head injury has an intracranial pressure of 18 mm Hg; blood pressure is 144/90 mm Hg and mean arterial pressure is 108mm Hg. What is the cerebral perfusion pressure. A. 54 mm Hg B. 72 mm Hg C. 90 mm Hg D. 126 mm Hg

C

1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 bpm, respiratory rate 30 breaths/min and temperature of 100.5 F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patients plan of care. A. Frequent neurological assessments B. Side to side position changes C. Range of motion to extremities D. Frequent orpharyngeal suctioning

A

Which patient being cared for in the emergency department should the charge nurse evaluate first? A. A patient with a complete spinal injury at the C5 dermatome level B. A patient with a Glasgow coma scale score of 15 on 3 L nasal cannula C. An alert patient with a subdue alert bleed who is complaining of a headache D. An ischemic stroke patient with a blood pressure of 190/200 mm Hg

A

The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? A. Keep the neck in the hyperextended position B. Maintain proper head and neck alignment C. Prepare for immediate endotracheal intubation D. Remove cervical collar upon arrival to the ED

B

The nurse caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patients blood pressure to be 160/90 mm Hg. What is the best action by the nurse A. Stop the infusion for 5 mins B. Increase the dose by 2.5 mg/hr C. Notify the physician of the BP D. Begin weaning the infusion

B

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergency intubation and mechanical ventilation what is the priority nursing A. Maintain body temperature B. Monitor blood pressure C. Pad all bony prominences D. Use proper hand washing

B

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60, heart rate 115, RR 28, O2 99% on supplemental oxygen at 3L/min b cannula, Glasgow coma scale of 4 and a central venous pressure (CVP) of 2 mm Hg. After reviewing the orders which order is of the highest priority. A. Furosemide 20 mg intravenous push as needed B. 500 mL albumin intravenous infusion C. Decadron 10 mg intravenous push D. Dilantin 50 mg intravenous push

B

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is reporting a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 bmp, RR 24 breaths/min and 50mL of urine via indwelling catheter for the past 4 hours. What is the best action by the nurse? A. Administer acetaminophen as ordered for the headache B. Assess for a kinked urinary catheter and assess for bowel impaction C. Encourage the patient to take slow, deep breaths D. Notify the physician of the patients blood pressure

B

The nurse is to administer 100 mg phenytoin intravenous. Vital signs assessed by the nurse include BP 90/60, HR 52, RR 18, O2 99% on supplemental oxygen at 3L/min by cannula. To prevent complications, what is the best action by the nurse A. Administer over 2 mins B. Administer over 5 mins C. Mix medications with 0.9% normal saline D. Administer via central line

B

The nursing is caring for a patient admitted to the emergency department n status eplilepticus. Vital signs assessed by the nurse include BP 160/100, HR 145, RR 36, O2 96% on 100% supplemental oxygen by non rebreather mask. After establishing an IV line which order should the nurse implement first? A. Obtain stat serum electrolytes B. Administer lorazepam C. Obtain stat portable chest X-ray D. Administer phenytoin

B

The primary care provider orders fosphenytoin 1.5 g intravenous loading dose for a 75 kg patient in status epilepticus. What is the most important action by the nurse? A. Contact primary care provider to discuss the order B. Administer the drug at a slow infusion rate C. Mix medication with 0.9% normal saline D. Administer via central line

B

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? A. PH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg B. PH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg C. PH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg D. PH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg.

C

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? A. Altered cerebral spinal fluid production and reabsorption B. Decreased cerebral blood volume due to vessel construction C. Increased cerebral blood volume due to vessel dilation D. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)

C

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure of 95/50 mm Hg, HR 110 bpm, RR 20, O2 95% on 3L/min oxygen via nasal cannula and a temp of 101.5 F. Which order should the nurse institute first? A. Blood cultures (2 specimens) for temperature >101 F B. Acetaminophen 650 mg per rectum C. 500 mL albumin infusion intravenously D. Decadron 20 mg intravenous push q 4 hours

C

The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include BP 110/70, HR 110, RR 30, O2 95% on supplemental oxygen at 3L/min and a temp of 103.5 F. What is the priority nursing action? A. Elevate the head of bed 30 degrees B. Keep lights dim at all times C. Implement seizure precautions D. Maintain bed rest at all times

C

The primary care provider has opted to treat a patient with a complete spinal cord injury with glucocorticoids, the orders are 30 mg/kg over 15 mins followed in 45 mins with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24 hours dose for the 70 kg patient. A. 2478 mg B. 5000 mg C. 20,794 mg D. 12,750 mg

C

While caring for a patient with a basilar skull fracture, the nurse assess clear drainage from the patients left marks. What is the best nursing action? A. Have the patient blow the nose until clear B. Insert bilateral cotton nasal packaging C. Place a nasal drip under the nose D. Suction the left nares until the drainage clears.

C

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? A. Hyper-oxygenate during endotracheal suctioning B. Elevate the patients head of the bed 30 degrees C. Apply bilateral heel protectors after repositioning D. Provide rest periods between nursing interventions

D

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assess a GCS score of 3. What is the priority nursing action? A. Stimulate the patient hourly B. Continue to monitor the patient C. Elevate the head of the bed D. Notify the primary care provider immediately

D

The nursing is caring for a patient admitted to the ED following a fall from a 10 foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes brushing behind the left ear and straw colored drainage from the left nare. What is the most appropriate nursing action? A. insert bilateral ear plugs B. Monitor airway patency C. Maintain neutral head position D. Apply a small nasal drip pad

D