A client with severe TBI on ICP monitor develops new BP 198/56, HR 42, and irregular respirations. Which actions should the nurse anticipate? Select all that apply.

Select All That Apply

Choose your responses, then check the answer.

1 Recognize Cushing triad as a sign of impending herniation and notify provider stat 2 Prepare for emergent neurosurgical decompression (craniectomy or hematoma evacuation) 3 Administer hyperosmolar therapy: hypertonic saline (3 percent or 23.4 percent bolus) or mannitol 4 Briefly hyperventilate to PaCO2 30-35 as bridge to definitive decompression 5 Place the client in a supine position with the head flat to promote cerebral perfusion.

Explanation

Cushing triad (HTN, bradycardia, irregular respirations) plus anisocoria signals impending or active herniation in TBI — emergent action: hyperosmolar therapy (3 percent NaCl bolus 250 mL or 23.4 percent 30 mL or mannitol 1 g/kg), brief hyperventilation to PaCO2 30-35 as a BRIDGE only (sustained low PaCO2 worsens ischemia), and emergent neurosurgical decompression. HOB FLAT worsens ICP — keep at 30 degrees with neutral neck. CSF drainage if EVD present.

Next question on this topicA nurse is programming a high-alert IV medication on a smart infusion pump. Which actions …From this question bank[전통+신유형] NCLEX LEVEL UP 패키지KRW 79,000

Browse all questions No login required

Master the NCLEX-RN with MyMerci

Thousands of NCLEX-style questions with detailed rationale — in your language. Track your progress and study smarter.

Start for free

App Store Google Play

Read in another language: English 한국어 日本語繁體中文 Tiếng Việt

For study reference only. Always follow current clinical guidelines and your institution’s protocols.

Next question Start for free

성장을 멈추지 마세요

A client with severe TBI on ICP monitor develops new BP 198/56, HR 42, and irregular respirations. Which actions should the nurse anticipate? Select all that apply.

Select All That Apply

Master the NCLEX-RN with MyMerci