The nurse cares for the client in the intensive care unit. Select all the nursing actions that apply.

Maintain head of bed elevation at 15 degrees or less.

Provide oxygen therapy to maintain oxygen saturation above 92

Keep lights dim in client's room to accommodate photophobia

Assess the client for headaches and behavior changes frequently

Minimize suctioning or hyper-oxygenate client before suctioning

Answer and Explanation

Correct Answer : B,D,E

A. Maintain head of bed elevation at 15 degrees or less: For a patient with increased intracranial pressure (ICP), the head of the bed should typically be elevated 30 degrees, not limited to 15 degrees. Proper elevation promotes venous drainage from the brain and helps reduce ICP, making 15 degrees insufficient for effective ICP management.

B. Provide oxygen therapy to maintain oxygen saturation above 92: Maintaining adequate oxygenation is critical in patients with neurological injury. Hypoxia can worsen cerebral ischemia and increase ICP, so oxygen therapy should be titrated to keep SpO₂ within the prescribed safe range, typically above 92%, to support cerebral perfusion and prevent secondary brain injury.

C. Keep lights dim in client's room to accommodate photophobia: While dim lighting can increase comfort in patients with migraine or photophobia, it does not directly affect ICP management. This action is supportive but not a priority intervention in caring for a patient with increased ICP.

D. Assess the client for headaches and behavior changes frequently: Frequent neurological assessment, including monitoring for changes in level of consciousness, behavior, and headache, is essential for early detection of worsening ICP or complications. These assessments guide timely interventions and are critical in intensive care management of post-stroke patients.

E. Minimize suctioning or hyper-oxygenate client before suctioning: Suctioning can stimulate coughing and increase ICP. To prevent sudden spikes in ICP, suctioning should be minimized and performed only when necessary, with pre-oxygenation to maintain cerebral oxygenation and reduce secondary brain injury risk.

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Correct Answer is B

Explanation

A. Draw blood to type and crossmatch for transfusions: Obtaining blood for transfusion is important for managing hemorrhagic shock, but it does not immediately address the patient’s oxygenation status. Delaying oxygen administration could worsen hypoxia and organ perfusion.

B. Administer oxygen at 100% per non-rebreather mask: The priority in shock is ensuring adequate tissue oxygenation. Administering high-flow oxygen immediately improves oxygen delivery to vital organs and supports cellular metabolism while other interventions, such as establishing IV access and preparing for transfusion, are initiated.

C. Insert two 20-gauge IV catheters: Establishing IV access is essential for fluid resuscitation and medication administration. However, oxygenation takes precedence because inadequate oxygen delivery can rapidly lead to cellular injury or death, making it the first action.

D. Place the patient on continuous cardiac monitor: Continuous cardiac monitoring is important to detect dysrhythmias associated with shock, but it does not immediately improve oxygenation or perfusion. Life-sustaining interventions such as oxygen delivery take higher priority.

A. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain B. A patient with full-thickness leg burns who has a dressing change scheduled C. A patient with 40% total body surface area (TBSA) bums who is receiving IV fluids at 500 mL/hour D. A patient with smoke inhalation who has wheezes and altered mental status

Correct Answer is D

Explanation

A. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain: Severe pain is expected in partial-thickness burns and requires prompt analgesia, but it does not typically represent an immediate life-threatening complication. Pain management is important but it does not supersede airway or breathing concerns in priority assessment.

B. A patient with full-thickness leg burns who has a dressing change scheduled: Full-thickness burns may be less painful due to nerve destruction, and a scheduled dressing change is a planned intervention. While wound care is essential to prevent infection and promote healing, it does not represent an urgent, unstable condition requiring immediate assessment at shift change.

C. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour: A patient with extensive burns is at high risk for hypovolemic shock due to capillary leak and fluid shifts. If the patient is already receiving aggressive fluid resuscitation and there are no reported signs of instability, this reflects ongoing management

D. A patient with smoke inhalation who has wheezes and altered mental status: Smoke inhalation can lead to airway edema, bronchospasm, carbon monoxide poisoning, and impending airway obstruction. Wheezing suggests lower airway involvement, while altered mental status may indicate hypoxia or carbon monoxide toxicity. Airway and breathing take highest priority.

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