A patient with a traumatic brain injury is being evaluated for ...

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A patient with a traumatic brain injury is being evaluated for brain death. Which findings should the nurse expect in this patient?
 
  Select all that apply.
  1. absence of gag or corneal reflex
  2. absence of oculovestibular reflex
  3. apnea with PaCO2 of 66 mmHg
  4. toxic metabolic disorders
  5. response to deep stimuli

Question 2

A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. Which solution does the nurse recognize would be best for this patient?
 
  1. Ringer's lactate
  2. Dextrose 5 and water
  3. Dextrose 5 and 0.45 normal saline
  4. Dextrose 5 and 0.9 normal saline

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Answer to Question 1

Correct Answer: 1,2,3

An absence of gag or corneal reflex, an absence of oculovestibular reflex, and apnea with PaCO2 of 66 mmHg are clinical signs consistent with brain death. Toxic metabolic disorders and responding to deep stimuli are not signs consistent with brain death.

Answer to Question 2

Correct Answer: 1

Ringer's lactate and 0.9 saline are the fluids of choice in treating hypovolemic shock, especially in the emergency phase of care while blood is being typed and crossmatched. Large amounts of these solutions may be infused rapidly, increasing blood volume and tissue perfusion. Hypotonic crystalloid solutions, such as dextrose 5 in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But approximately 25 of the fluid stays within the intravascular space, increasing the risk of peripheral edema.