A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care?

Rationale:

A. Allow extra time for the client to perform tasks: Clients with vision loss may need additional time to orient themselves, perform activities of daily living, and navigate safely. Allowing extra time supports independence and reduces the risk of injury or frustration.

B. Touch the client gently to announce presence: Gently touching the client on the arm or shoulder before speaking helps prevent startling them and provides a clear cue that someone is nearby. This enhances safety and effective communication for clients with impaired vision.

C. Keep objects in the client's room in the same place: Consistently organizing personal items and equipment in fixed locations helps clients with vision loss locate items safely and reduces the risk of tripping or injury. This is an essential component of creating a safe environment.

D. Ensure there is high-wattage lighting in the client's room: Excessive or harsh lighting can cause glare, which may worsen visual difficulties for clients with certain types of vision loss. Appropriate lighting should be sufficient but not overly bright, emphasizing contrast rather than intensity.

E. Approach the client from the side: Approaching from the side may startle a client with vision loss. It is safer and more effective to approach from the front while identifying oneself to maintain clear communication and orientation.

Rationale for correct choices

• obtain IV access: The client’s blood pressure has dropped significantly from 90/50 mm Hg to 76/45 mm Hg, and heart rate is elevated, indicating hypovolemic shock likely due to gastrointestinal bleeding. Establishing IV access is critical to provide rapid fluid resuscitation and allow administration of medications or blood products as needed.

• prepare to administer IV fluids: With hypotension and tachycardia, the client requires fluid resuscitation to restore circulating volume and improve perfusion prior to undergoing an invasive procedure like endoscopy. IV fluids will help stabilize hemodynamics and reduce the risk of complications during the procedure.

Rationale for incorrect choices

• recheck the client’s oxygen saturation: The client’s oxygen saturation is stable at 98% on room air, indicating adequate oxygenation. While monitoring is important, it does not address the more urgent issue of hypovolemia.

• call the surgical suite to notify that the client is arriving STAT: Notifying the suite is necessary for scheduling, but immediate intervention to stabilize the client’s hemodynamic status takes precedence over notification. Transport should not occur until the client is stabilized.

• place the client in a supine position with feet elevated: While this may provide temporary support for hypotension, it does not treat the underlying hypovolemia. IV access and fluid resuscitation are more effective and urgent interventions.

• check an ECG: Although ECG monitoring may be helpful in hypotensive clients, it is not the immediate priority over fluid resuscitation and IV access.

• check an arterial blood gas: ABG analysis is not immediately necessary because the client’s oxygenation is adequate and the priority is stabilizing circulation.

• transport the client for endoscopy: Transporting the client before hemodynamic stabilization would be unsafe given hypotension and tachycardia. Resuscitation must occur prior to the procedure.