HESI Bsn 225 RN Pharmacology | Nurselytic

Questions 52

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HESI Bsn 225 RN Pharmacology Questions

Extract:

History and physical
The client is a 24-year-old female who was hit by a car while riding her bicycle. She was wearing a helmet, but her head struck the windshield of the vehicle at approximately 40 miles per hour (mph).
Nurses notes
1800
Client is intubated and on a ventilator. Breath sounds clear and equal. Pupils are 3 mm and sluggish. Responds to painful stimuli. Intracranial pressure 12 mm Hg. Pulses 2+ in all extremities. Capillary refill 2 seconds.
1900
Pupils are 3 mm and sluggish. Client is unresponsive to painful stimuli. Intracranial pressure 24 mm Hg. Healthcare provider (HCP) notified of status. Mannitol given as prescribed.
2000
Breath sounds clear and equal. Pupils are 4 mm and sluggish. Now responds to painful stimuli. Intracranial pressure 11 mm Hg. Has some dependent peripheral edema noted.
Flowsheet
Heart rate 79 beats/minute • Respiratory rate 18 breaths/minute
Blood pressure 111/79 mm Hg
Oxygen saturation 99% on ventilator
Orders
Admit to the surgical intensive care unit
Monitor intracranial pressure every hour
Lactated Ringer's 100 mL/hr IV infusion
Vital signs every hour
Neurological check every hour
Complete blood count, blood gas, and chemistry every 4 hours
Imaging
Head CT scan: cerebral edema


Question 1 of 5

Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions.Click to mark whether the assessment finding represents a therapeutic result of the mannitol administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.

OptionsTherapeutic resultNon therapeutic side effectUnrelated finding
Peripheral edema: Non-therapeutic side effect
Potassium 2.9: Non-therapeutic side effect
Urine output 280 ml: Therapeutic result
Heart rate 79: Unrelated finding
Intracranial pressure 11mmHg: Therapeutic result
Oxygen saturation: Unrelated finding

Correct Answer:

Rationale: A: Edema is a mannitol side effect. B: Hypokalemia is a side effect. C: Increased urine output is therapeutic. D: Normal heart rate is unrelated. E: Reduced intracranial pressure is therapeutic. F: Normal oxygen saturation is unrelated.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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Rationale:

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