Difficulty: Medium
Average Score: 73%
Simulated
A nurse is caring for a client who has a traumatic brain injury and is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent intracranial pressure (ICP) elevation?
Correct answer
A
Rationale
Correct Answer: A - Maintain the head of the bed at a 30-degree angle.
Rationale: Keeping the head of the bed at a 30-degree angle helps promote venous drainage from the brain, reducing intracranial pressure. This position helps prevent further complications in clients with traumatic brain injuries on mechanical ventilation.
Summary:
B: Suctioning the endotracheal tube every 2 hours may be necessary for airway clearance but does not directly address intracranial pressure.
C: Administering mannitol as prescribed is a treatment for reducing intracranial pressure but does not address preventative measures.
D: Hyperventilating the client during suctioning can lower CO2 levels, causing vasoconstriction and potentially exacerbating intracranial pressure.
Rationale: Keeping the head of the bed at a 30-degree angle helps promote venous drainage from the brain, reducing intracranial pressure. This position helps prevent further complications in clients with traumatic brain injuries on mechanical ventilation.
Summary:
B: Suctioning the endotracheal tube every 2 hours may be necessary for airway clearance but does not directly address intracranial pressure.
C: Administering mannitol as prescribed is a treatment for reducing intracranial pressure but does not address preventative measures.
D: Hyperventilating the client during suctioning can lower CO2 levels, causing vasoconstriction and potentially exacerbating intracranial pressure.