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. Evaluate why the client was not ambulated.: The first step in addressing a missed delegated task is to assess the reason it was not completed. Understanding whether barriers were related to the AP, client condition, workload, or communication helps the nurse plan corrective action and prevents recurrence.

B. Ambulate the client on behalf of the AP.: While ensuring the client’s needs are met is important, jumping straight to performing the task bypasses assessment of the underlying issue. Immediate action may address the symptom but not the cause of the missed delegation.

C. Supervise the AP performing the task.: Supervision is appropriate for ongoing tasks but is not the first action once a task has already been missed. The nurse must first determine why the task was not completed before implementing supervision.

D. Remind the AP of her assigned tasks.: Reminding the AP without assessing why the task was missed does not address potential systemic or situational barriers. It may be necessary later but is not the initial step in problem resolution.

Rationale for correct choices

• Report to the provider immediately if a dry cough develops: ACE inhibitors or similar antihypertensive medications can cause a persistent dry cough as a side effect. Early reporting allows the provider to evaluate the need for medication adjustment or substitution to prevent further complications, such as noncompliance or worsening respiratory symptoms.

• Report to the provider immediately if the client experiences muscle aches: Muscle aches or myalgia can indicate statin-induced myopathy or rhabdomyolysis, particularly with elevated LDL and prescription of statins such as rosuvastatin. Early detection prevents severe muscle breakdown, renal impairment, or other complications.

Rationale for incorrect choices

• Increase sodium intake: The client has hypertension, and increasing sodium intake would exacerbate elevated blood pressure and increase the risk of cardiovascular complications, including heart failure and stroke. Sodium restriction is essential to support blood pressure control and overall cardiovascular health.

• Take rosuvastatin only in the morning: Rosuvastatin can be taken at any time of day, unlike some other statins that are recommended in the evening. Restricting it to the morning is unnecessary and may reduce adherence if it conflicts with the client’s routine. Emphasis should be on consistent daily intake rather than timing.