A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

Elevate the client's head on two pillows

Decrease the noise level in the client's room

Suction the endotracheal tube frequently

Administer a stool softener

Give a 500cc NS fluid bolus

Answer and Explanation

Correct Answer : B,D,E

Choice A reason:

Elevating the client's head on two pillows is not a standardized method for managing intracranial pressure. Instead, elevating the head of the bed to 30 degrees is a more effective strategy to promote venous drainage and reduce ICP.

Choice B reason:

Decreasing the noise level in the client's room helps create a calm environment, which can reduce stress and prevent increases in ICP. Excessive noise and stimulation can elevate intracranial pressure.

Choice C reason:

Frequent suctioning of the endotracheal tube can actually increase ICP due to the stimulation and potential for causing a cough reflex. Suctioning should be performed only as necessary and with care.

Choice D reason:

Administering a stool softener helps prevent straining during bowel movements, which can increase ICP. Ensuring regular and comfortable bowel movements is crucial in managing intracranial pressure.

Choice E reason:

Giving a 500cc NS fluid bolus can be appropriate in some clinical scenarios to maintain adequate blood pressure and perfusion. However, fluid management must be carefully balanced to avoid fluid overload, which could increase ICP. Generally, fluid boluses are not the primary method for managing ICP.

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Correct Answer is A

Explanation

Choice A reason:

Administering Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain should be the nurse's priority because chest pain can be indicative of a myocardial infarction (heart attack), which is a medical emergency. Quick administration of Nitroglycerin can help to relieve chest pain, improve blood flow to the heart, and prevent further cardiac damage.

Choice B reason:

While administering Lorazepam 2 mg IV for the client experiencing restlessness and picking at tubing is important for patient safety and comfort, it is not as urgent as addressing potential cardiac issues indicated by chest pain.

Choice C reason:

Administering Morphine sulfate 4 mg IV for incisional pain management is necessary for the patient’s comfort and pain control but is not as critical as treating potential life-threatening chest pain.

Choice D reason:

Administering one unit of packed red blood cells STAT for the client with a hemoglobin of 9.5 g/dL is important but does not take precedence over the immediate risk of a myocardial infarction. The hemoglobin level, while low, is not immediately life-threatening compared to the chest pain scenario.

A. Suctioning the patient on a regular schedule. B. Adherence to proper hand hygiene. C. Administering antiulcer medication. D. Providing oral care per protocol. E. Elevating the head of the bed.

Correct Answer is ["B","D","E"]

Explanation

Choice A reason:

Suctioning the patient on a regular schedule is not recommended as it can increase the risk of infection and trauma to the airway. Suctioning should be done as needed based on clinical assessment.

Choice B reason:

Adherence to proper hand hygiene is a fundamental practice in preventing infections, including ventilator-associated pneumonia. Hand hygiene helps prevent the transmission of pathogens.

Choice C reason:

Administering antiulcer medication is important for preventing stress ulcers but is not directly related to preventing ventilator-associated pneumonia.

Choice D reason:

Providing oral care per protocol is essential in reducing the risk of ventilator-associated pneumonia. Oral care helps decrease the bacterial load in the oropharynx and prevent aspiration of contaminated secretions.

Choice E reason:

Elevating the head of the bed to 30-45 degrees helps prevent aspiration of gastric contents and is a key practice in preventing ventilator-associated pneumonia.

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A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

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