A nurse in the operating room is caring for a client who suddenly develops muscle rigidity and a rise in body temperature. What emergency medication should the nurse expect to receive an order to start administering?

Choice A reason:

Monitoring the Glasgow Coma Scale (GCS) is used to assess a client's level of consciousness, typically in cases of head injury or altered mental status. It is not relevant to the assessment of a pressure injury, which requires evaluating the risk factors and extent of skin damage.

Choice B reason:

Completing the Braden Scale is the appropriate action for assessing a client with a pressure injury. The Braden Scale evaluates risk factors for pressure ulcers, including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This tool helps in creating an effective care plan to prevent further skin breakdown and manage existing ulcers.

Choice C reason:

Initiating a Brudzinski flow sheet pertains to neurological assessment, specifically testing for signs of meningitis. It is not relevant to the assessment or management of pressure injuries in a paraplegic client.

Choice D reason:

Assessing for Babinski's sign is a neurological test to evaluate corticospinal tract function. While important in a complete neurological examination, it does not address the specific needs related to pressure injury assessment and management.

Choice A reason:

Assessing sputum characteristics is important in monitoring respiratory conditions but does not directly precede preparing a client for postural drainage. It assesses the infection or inflammation severity, providing valuable data for treatment but isn't the immediate preparatory step for drainage.

Choice B reason:

Assessing pulse and respirations is critical before starting postural drainage as it establishes the client’s baseline vital signs and ensures they can tolerate the procedure. Monitoring these vital signs throughout ensures safety and effectiveness of the procedure. Thus, it’s the essential first step.

Choice C reason:

Instructing on pursed-lip exhalation aids in managing respiratory conditions by promoting effective breathing patterns but is not the immediate first step before percussion and postural drainage. It serves more as a therapeutic breathing technique.

Choice D reason:

Auscultating lung fields identifies lung sounds and areas needing drainage but isn’t the initial action. While important for confirming indications and evaluating effectiveness, it follows baseline assessments like pulse and respirations.