Question

The nurse is caring for a client who has just undergone surgery to evacuate a subdural hematoma. Which assessment is the nurse's priority in the immediate postoperative period?

Answer 1

Correct Answers:

Neurological status assessment

Rationale :

🔷 Neurological assessment is the priority because the client has just had surgery involving the brain, so the nurse must quickly detect any change in level of consciousness, pupil response, motor function, or signs of increased intracranial pressure.

🔷 After evacuation of a subdural hematoma, complications such as rebleeding, cerebral edema, worsening intracranial pressure, or neurologic deterioration can occur in the immediate postoperative period.

🔷 Frequent neurologic checks provide the earliest warning that the client’s condition is worsening and that urgent intervention is needed.

🔷 Although airway, breathing, and circulation are always important, this question asks for the priority assessment specific to this postoperative neurosurgical client, and that is the neurologic exam.

🔷 For these reasons, neurological status assessment is the most important immediate postoperative priority.

Blood glucose levels

🔷 Blood glucose monitoring may be important in some postoperative clients, but it is not the most urgent assessment after evacuation of a subdural hematoma.

🔷 The greatest immediate risk is neurologic deterioration, not glucose imbalance.

Oxygen saturation

🔷 Oxygen saturation is important to monitor, but it is not the most specific priority compared with frequent neurologic assessment after cranial surgery.

🔷 The nurse must first focus on detecting changes that directly reflect worsening brain function or intracranial complications.

Pain level

🔷 Pain assessment is necessary, but pain is not the top priority over monitoring for life-threatening neurologic changes.

🔷 In the immediate postoperative neurosurgical period, the nurse must first identify signs of rebleeding or increased ICP.

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Answer 2

Correct Answers:

"Platelets should be infused over 15-30 minutes and monitored closely."

Rationale :

🟣 Platelets are usually administered relatively rapidly, commonly over about 15 to 30 minutes per unit, because they have a short shelf life and are given when prompt correction of thrombocytopenia is needed.

🟣 Clients receiving platelets, especially those with DIC and sepsis, must be monitored closely for transfusion reactions, volume issues, and response to therapy.

🟣 Prompt infusion is important because platelets are often given in actively bleeding or high-risk clients who need quick hemostatic support.

🟣 Blood administration tubing with the proper setup, including a filter, is standard practice for blood products.

🟣 For these reasons, the correct statement is that platelets should be infused over 15 to 30 minutes and monitored closely.

"Platelets should be given through a peripheral IV without a filter."

🟣 Blood products, including platelets, should be infused with the appropriate administration set that includes a filter.

🟣 Saying they should be given without a filter is incorrect and unsafe.

"Platelets can be infused over an extended period, such as 2 hours, for better tolerance."

🟣 Platelets are not typically infused over an unnecessarily prolonged time because delayed administration reduces timely therapeutic effect and may increase risk.

🟣 They are generally given more rapidly, with close monitoring during the transfusion.

"Platelets must always be combined with fresh frozen plasma for optimal effect."

🟣 Platelets and fresh frozen plasma may both be used in DIC depending on the coagulation problem, but they are not required to be given together in every case.

🟣 Therapy is based on the client’s laboratory findings and bleeding status, not an automatic combination rule.

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Answer 3

Correct Answers:

Gabapentin

Rationale :

💠 Gabapentin should be questioned as the best answer in this item because the established disease-modifying treatments for Guillain-Barré syndrome are intravenous immunoglobulin (IVIG) and plasma exchange, while gabapentin is not a primary treatment for the underlying disorder.

💠 GBS is an acute autoimmune polyneuropathy, so therapy focuses on reducing immune-mediated nerve injury rather than using medications aimed mainly at symptomatic neuropathic pain control.

💠 Although pain may occur in GBS and supportive medications can be used, gabapentin does not treat the core disease process.

💠 Since the question asks which treatment should be questioned in the prescribed regimen, the nurse should identify the option that is not a standard primary GBS therapy.

💠 For these reasons, gabapentin is the treatment the nurse should question in this question set.

Opiates

💠 Opiates may be used for pain management if the client has significant discomfort.

💠 They do not treat the disease itself, but they can be appropriate as supportive symptomatic therapy.

Immunoglobulin therapy

💠 Immunoglobulin therapy is a standard and appropriate treatment for GBS.

💠 It helps reduce the immune attack on peripheral nerves and is one of the main evidence-based therapies.

Plasma exchange

💠 Plasma exchange is also a standard treatment for GBS.

💠 It works by removing circulating antibodies and immune factors involved in nerve damage.

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Answer 4

Correct Answers:

Mannitol

Rationale :

✅ Mannitol is an osmotic diuretic that is highly effective for reducing increased intracranial pressure because it pulls fluid from the brain tissue into the vascular space.

✅ This osmotic shift helps reduce cerebral edema and lowers pressure within the skull.

✅ Mannitol is commonly used in acute neurologic emergencies involving elevated ICP because its effect is more direct and clinically significant than standard diuretics for this purpose.

✅ The nurse must also monitor fluid status, renal function, and serum osmolality when it is used.

✅ For these reasons, mannitol is the most effective choice for reducing increased ICP.

Furosemide

✅ Furosemide is a loop diuretic and may sometimes be used as an adjunct, but it is not the most effective primary agent for rapidly reducing ICP.

✅ Mannitol is the better answer because it directly creates an osmotic shift out of brain tissue.

Hydrochlorothiazide

✅ Hydrochlorothiazide is a thiazide diuretic used mainly for fluid balance and hypertension, not acute reduction of intracranial pressure.

✅ It does not have the same rapid osmotic action needed in cerebral edema.

Spironolactone

✅ Spironolactone is a potassium-sparing diuretic and is not used as the primary treatment for elevated ICP.

✅ Its mechanism is not appropriate for rapid reduction of brain swelling.

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Answer 5

Correct Answers:

Muscle weakness

Rationale :

🔶 In myasthenia gravis, antibodies interfere with acetylcholine receptors at the neuromuscular junction, so normal nerve impulses cannot effectively stimulate muscle contraction.

🔶 Because the transmission of the signal is impaired, the muscles become weak and fatigable, especially with repeated use.

🔶 This weakness commonly affects the eyes, face, swallowing muscles, and proximal limb muscles, but it can progress to more generalized weakness.

🔶 The problem is not excessive contraction; it is failure of adequate muscle activation.

🔶 For these reasons, the expected result is muscle weakness.

Hyperreflexia

🔶 Hyperreflexia is not the hallmark of myasthenia gravis because the disorder affects the neuromuscular junction, not the upper motor neuron pathways.

🔶 The key problem is weakness, not exaggerated reflexes.

Muscle spasms

🔶 Muscle spasms are not the classic consequence of impaired acetylcholine receptor binding in myasthenia gravis.

🔶 The client is more likely to experience fatigable weakness than spasm.

Increased muscle contraction

🔶 In myasthenia gravis, muscle contraction is decreased, not increased, because acetylcholine cannot bind effectively.

🔶 The impaired neuromuscular transmission leads to reduced strength.

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Answer 6

Correct Answers:

14

Rationale :

✍️Formula:

🌟mL × drop factor ÷ time in minutes

🌟500 mL × 20 gtt/mL = 10,000 gtt

🌟 12 hours = 720 minutes

🌟10,000 ÷ 720

📌13.9

📌Rounded to the nearest whole number, the drip rate is 14 gtt/min.

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Answer 7

Correct Answers:

"You should avoid using cushions or supports while sitting, as they can cause pressure."

Rationale :

💎 This statement is inappropriate because clients with ALS are at increased risk for pressure injuries due to immobility and muscle weakness, and cushions or supports are often helpful in reducing pressure.

💎 Properly selected cushions help redistribute weight, improve positioning, and decrease prolonged pressure over bony prominences.

💎 Discouraging their use would remove an important preventive measure for skin breakdown.

💎 Skin protection in ALS requires supportive surfaces, repositioning, hydration, and routine inspection.

💎 For these reasons, telling the client to avoid cushions or supports is the inappropriate statement.

"Since ALS can affect muscle strength, you will be more prone to developing pressure ulcers."

💎 This is an appropriate teaching statement because weakness and reduced mobility increase the risk of pressure injury.

💎 It correctly explains why skin care prevention is so important in ALS.

"Frequent repositioning is essential to prevent skin breakdown."

💎 This is appropriate because frequent repositioning is one of the main interventions for pressure injury prevention.

💎 It helps reduce prolonged pressure and improve tissue perfusion.

"Dry skin can increase your risk for breakdown, so we should apply moisturizing lotion regularly."

💎 This is also an appropriate teaching statement because dry skin is more vulnerable to cracking and injury.

💎 Moisturizing, along with inspection and pressure relief, supports skin integrity.

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Answer 8

Correct Answers:

Tachycardia
Restlessness
Cool, clammy skin
Tachypnea
Decreased urine output

Rationale :

Tachycardia

🟡 Tachycardia is an expected early sign of hypovolemic shock because the body tries to compensate for reduced circulating volume by increasing the heart rate.

🟡 Major burns cause large fluid shifts out of the vascular space, which lowers effective perfusion.

🟡 The heart responds by beating faster to maintain cardiac output.

🟡 This compensatory response is common in early shock.

🟡 Therefore, tachycardia is an expected finding.

Restlessness

🟡 Restlessness is an early indicator of decreased cerebral perfusion and hypoxia in shock states.

🟡 Clients may become anxious, restless, or confused before more obvious signs of decompensation appear.

🟡 This finding should never be dismissed because it may signal worsening tissue perfusion.

🟡 In burn-related hypovolemia, reduced oxygen delivery to the brain contributes to this symptom.

🟡 For these reasons, restlessness is an expected manifestation.

Cool, clammy skin

🟡 Cool, clammy skin occurs because the body shunts blood away from the skin to preserve perfusion to vital organs.

🟡 Vasoconstriction is a classic compensatory response in hypovolemic shock.

🟡 Even though burns affect the skin, systemic shock still produces peripheral vasoconstriction in less-injured areas.

🟡 This finding supports worsening circulatory compromise.

🟡 Therefore, cool, clammy skin is anticipated.

Tachypnea

🟡 Tachypnea is common in shock because the body attempts to improve oxygen delivery and compensate for metabolic acidosis.

🟡 As tissue perfusion decreases, anaerobic metabolism increases, leading to lactic acid buildup.

🟡 Faster breathing helps compensate for this metabolic imbalance.

🟡 It also reflects physiologic stress and oxygen demand.

🟡 For these reasons, tachypnea is expected in hypovolemic shock.

Decreased urine output

🟡 Decreased urine output is an important sign of reduced renal perfusion in shock.

🟡 As circulating volume falls, the kidneys receive less blood flow and urine production decreases.

🟡 Oliguria is one of the clearest indicators that organ perfusion is being compromised.

🟡 In burn shock, strict urine output monitoring is essential.

🟡 Therefore, decreased urine output is an expected manifestation.

Hypertension

🟡 Hypertension is not expected in hypovolemic shock.

🟡 The blood pressure typically trends downward as circulating volume is lost.

Hyperglycemia

🟡 Hyperglycemia may occur with stress responses, but it is not one of the hallmark bedside manifestations used to identify hypovolemic shock initially.

🟡 The more classic findings are changes in perfusion, pulse, breathing, skin, and urine output.

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Answer 9

Correct Answers:

PT 18 seconds

Rationale :

⚫ A prolonged PT, such as 18 seconds, suggests impaired clotting and supports the possibility of disseminated intravascular coagulation (DIC).

⚫ In DIC, clotting factors are consumed abnormally, so coagulation studies such as PT and often aPTT become prolonged.

⚫ The client is already oozing from the surgical site, which fits the bleeding tendency seen when clotting factors are depleted.

⚫ The other listed values are within or close to normal, but the prolonged PT is the abnormal result that indicates developing coagulopathy.

⚫ For these reasons, PT 18 seconds is the finding that indicates DIC is developing.

D-dimer 0.4 mcg/mL

⚫ A D-dimer of 0.4 mcg/mL is within the normal range provided and does not support DIC.

⚫ In DIC, D-dimer is usually elevated because of increased clot breakdown.

Fibrinogen 350 mg/dL

⚫ A fibrinogen of 350 mg/dL is within the normal range given.

⚫ In DIC, fibrinogen is often decreased because it is consumed.

Platelet count 170,000/microL

⚫ A platelet count of 170,000/microL is within the normal range provided.

⚫ In DIC, platelets are typically low because they are used up in widespread clotting.

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Answer 10

Correct Answers:

To dissolve the clot and restore blood flow to the affected brain tissue

Rationale :

🔷 The primary goal of thrombolytic therapy in acute ischemic stroke is to dissolve the obstructing clot and re-establish cerebral perfusion before more brain tissue becomes irreversibly injured.

🔷 Acute stroke treatment is aimed at saving the ischemic but still viable brain tissue, often called salvageable tissue, by restoring blood flow as quickly as possible.

🔷 This is why thrombolysis is used in the acute phase, when timely reperfusion can limit infarct expansion and improve outcomes.

🔷 Reducing long-term disability is an important benefit, but it happens because the clot is dissolved and blood flow is restored.

🔷 For that reason, the best answer is to dissolve the clot and restore blood flow to the affected brain tissue.

To reduce the risk of long-term disability

🔷 This is an important expected outcome of thrombolytic therapy, but it is not the primary immediate physiologic goal.

🔷 The direct acute goal is reperfusion of ischemic brain tissue.

To provide symptom relief and manage pain

🔷 Thrombolytics are not given mainly for pain relief or symptom comfort.

🔷 Their purpose is to recanalize the blocked vessel and improve cerebral blood flow.

To stabilize the client's blood pressure and heart rate

🔷 Blood pressure and heart rate management may be part of stroke care, but that is not the main function of thrombolytic therapy.

🔷 Thrombolysis specifically targets the clot causing the ischemic stroke.

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QLexNursing

1 :
The nurse is caring for a client who has just undergone surgery to evacuate a subdural hematoma. Which assessment is the nurse's priority in the immediate postoperative period?

2 :
The nurse is preparing to administer platelets to a client with disseminated intravascular coagulation (DIC) secondary to sepsis. Which of the following statements regarding platelet administration is correct?

3 :
The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is being started on a treatment regimen. The client has been prescribed several medications. Which treatment should the nurse question if prescribed for this client?

4 :
Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)?

5 :
In myasthenia gravis, the postsynaptic membranes of the neuromuscular junction are altered, preventing acetylcholine (ACh) from binding. This leads to:

6 :
The nurse is preparing to administer an IV solution to a client. The prescription states "500 mL Lactated Ringer's infused over 12 hours." The nurse is using an IV set with a drop factor of 20 gtt/mL. What is the drip rate of the infusion? Round the answer to the nearest whole number.

7 :
The nurse is caring for a client with amyotrophic lateral sclerosis (ALS) and is providing education on skin integrity. Which statement by the nurse would be inappropriate?

8 :
The nurse is caring for a client who has suffered a significant burn injury and is developing hypovolemic shock. What clinical manifestations of shock should the nurse anticipate during the initial assessment? (Select all that apply)

10 :
The nurse is preparing to care for a client who has had an ischemic stroke and is being started on thrombolytic therapy. What is the primary goal of this treatment during the acute phase?

QLexNursing

1 : The nurse is caring for a client who has just undergone surgery to evacuate a subdural hematoma. Which assessment is the nurse's priority in the immediate postoperative period?

2 : The nurse is preparing to administer platelets to a client with disseminated intravascular coagulation (DIC) secondary to sepsis. Which of the following statements regarding platelet administration is correct?

3 : The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is being started on a treatment regimen. The client has been prescribed several medications. Which treatment should the nurse question if prescribed for this client?

4 : Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)?

5 : In myasthenia gravis, the postsynaptic membranes of the neuromuscular junction are altered, preventing acetylcholine (ACh) from binding. This leads to:

6 : The nurse is preparing to administer an IV solution to a client. The prescription states "500 mL Lactated Ringer's infused over 12 hours." The nurse is using an IV set with a drop factor of 20 gtt/mL. What is the drip rate of the infusion? Round the answer to the nearest whole number.

7 : The nurse is caring for a client with amyotrophic lateral sclerosis (ALS) and is providing education on skin integrity. Which statement by the nurse would be inappropriate?

8 : The nurse is caring for a client who has suffered a significant burn injury and is developing hypovolemic shock. What clinical manifestations of shock should the nurse anticipate during the initial assessment? (Select all that apply)

10 : The nurse is preparing to care for a client who has had an ischemic stroke and is being started on thrombolytic therapy. What is the primary goal of this treatment during the acute phase?

1 :
The nurse is caring for a client who has just undergone surgery to evacuate a subdural hematoma. Which assessment is the nurse's priority in the immediate postoperative period?

2 :
The nurse is preparing to administer platelets to a client with disseminated intravascular coagulation (DIC) secondary to sepsis. Which of the following statements regarding platelet administration is correct?

3 :
The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is being started on a treatment regimen. The client has been prescribed several medications. Which treatment should the nurse question if prescribed for this client?

4 :
Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)?

5 :
In myasthenia gravis, the postsynaptic membranes of the neuromuscular junction are altered, preventing acetylcholine (ACh) from binding. This leads to:

6 :
The nurse is preparing to administer an IV solution to a client. The prescription states "500 mL Lactated Ringer's infused over 12 hours." The nurse is using an IV set with a drop factor of 20 gtt/mL. What is the drip rate of the infusion? Round the answer to the nearest whole number.

7 :
The nurse is caring for a client with amyotrophic lateral sclerosis (ALS) and is providing education on skin integrity. Which statement by the nurse would be inappropriate?

8 :
The nurse is caring for a client who has suffered a significant burn injury and is developing hypovolemic shock. What clinical manifestations of shock should the nurse anticipate during the initial assessment? (Select all that apply)

10 :
The nurse is preparing to care for a client who has had an ischemic stroke and is being started on thrombolytic therapy. What is the primary goal of this treatment during the acute phase?