The Unconscious Client

A nurse is caring for an unconscious client who was admitted following a traumatic brain injury. Which nursing intervention is the PRIORITY to prevent complications in this client?

1 Perform passive range-of-motion exercises every 2 hours
2 Maintain patent airway and monitor respiratory status continuously ✓ 정답
3 Turn the client every 2 hours to prevent pressure ulcers
4 Insert a urinary catheter to monitor fluid balance

해설

Maintaining airway patency and respiratory monitoring is the priority for unconscious clients due to compromised protective reflexes and high risk of airway obstruction. Other interventions like ROM exercises and turning are important but secondary to immediate life-threatening risks.

같은 주제 다음 문제A nurse is caring for an unconscious client with a traumatic brain injury. Which assessmen…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다69,000원

Understanding the Priority: Airway Management in Traumatic Brain Injury

The foundation of trauma care rests on a systematic approach, and for an unconscious client with a traumatic brain injury (TBI), the immediate and overarching priority is ensuring a patent airway and adequate ventilation. This principle is embedded in the globally recognized Essential Trauma Care guidelines, which emphasize that strengthening the organization of trauma care, starting with the most fundamental life-saving interventions, is critical to lowering mortality ^[2]. The rationale is rooted in pathophysiology: an unconscious patient loses protective airway reflexes, placing them at high risk for airway obstruction from the tongue, secretions, or aspiration. More critically, a TBI directly compromises the brain's respiratory centers, and post-traumatic apnoea is a major and potentially reversible contributor to early mortality, which can rapidly lead to hypoxic injury and death ^[3].

The clinical cascade is swift and devastating. An obstructed airway or respiratory depression leads to hypoxia and hypercapnia. For the injured brain, these are catastrophic secondary insults. Hypoxia deprives vulnerable neurons of oxygen, exacerbating the primary injury, while hypercapnia causes cerebral vasodilation, increasing cerebral blood volume and subsequently elevating intracranial pressure (ICP). This rise in ICP can further compromise cerebral perfusion pressure (CPP), creating a vicious cycle of worsening brain injury. Therefore, the intervention of maintaining a patent airway and continuously monitoring respiratory status is not merely a supportive measure; it is a direct, therapeutic action to prevent these secondary brain injuries ^[3].

While other interventions are important components of holistic care, they are secondary to airway and breathing. Turning the client to prevent pressure ulcers and performing passive range-of-motion exercises are crucial for long-term complication prevention but do not address an immediate threat to life. Inserting a urinary catheter for strict fluid balance monitoring is a valuable tool in managing a neurocritical care patient, particularly when therapies like targeted temperature management are employed . However, accurate output monitoring is irrelevant if the patient is not adequately oxygenating and ventilating. The nursing process mandates a hierarchy of needs based on threat to life, and in the unconscious TBI patient, a compromised airway is the most immediate lethal threat, making its management the absolute priority.

References (research sources)

[2]
Guidelines for Essential Trauma Care: Second Edition (2026).GuidelineMock C, Hardcastle TC, Gaarder C, Gupta A, Gyedu A, Joshipura M, Steyn E, Essential Trauma Care revision author group. (2026) · DOI: 10.1002/wjs.70321
[3]
Managing apnoea in trauma victims: the potential for dispatcher-assisted airway handling - a narrative review.Research articleImbriaco G, D'arrigo S, Limonti F, Rehn M, Cucino A. (2025) · DOI: 10.1186/s13049-025-01533-w

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A nurse is caring for an unconscious client who was admitted following a traumatic brain injury. Which nursing intervention is the PRIORITY to prevent complications in this client?

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