The nurse is caring for a client in the intensive care unit following a closed head injury. The nurse can anticipate which medication would be administered to treat an increase in intracranial pressure?

Choice A reason:

Directing the client to perform exercises of the ankle and toes is important for preventing complications like deep vein thrombosis and promoting circulation, but it is not the most critical intervention immediately postoperatively. The priority is to ensure there is no compromise to circulation and nerve function in the affected extremity.

Choice B reason:

While medicating the client for pain is crucial to ensure comfort and compliance with postoperative care, it does not take precedence over neurovascular checks. Pain management is an essential aspect of postoperative care but does not directly address potential complications such as compartment syndrome or impaired blood flow.

Choice C reason:

Performing neurovascular checks of the extremities is the most important intervention in the immediate postoperative period. These checks help detect early signs of complications like compartment syndrome, nerve damage, or compromised blood flow, which can lead to serious outcomes if not identified promptly. Ensuring the extremity has adequate circulation and sensation is vital.

Choice D reason:

Instructing the client on the use of crutches is important for mobility and rehabilitation but is not the highest priority immediately after surgery. Teaching crutch use typically occurs later in the recovery process, once the patient's immediate postoperative status is stable and free from complications.

Choice A reason: Obtaining a chest x-ray can provide important diagnostic information about the client's lung condition, but it is not the immediate first action. The priority is to address the low oxygen saturation to ensure adequate oxygenation.

Choice B reason: Raising the head of the bed can help improve oxygenation by facilitating easier breathing. However, in this scenario, the immediate need to increase oxygen levels through supplemental oxygen takes precedence over repositioning.

Choice C reason: Administering a prescribed analgesic might be necessary for pain management, but it does not address the critical issue of low oxygen saturation. The primary concern is to stabilize the client's oxygen levels first.

Choice D reason: This is the correct answer. Administering oxygen at 2 L/min is the most immediate and effective intervention to improve the client's oxygen saturation. Supplemental oxygen will help increase the oxygen levels in the blood, addressing the immediate need for adequate oxygenation.