# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375148&lang=en  
> language: en  
> subject: Pharmacological and Parenteral Therapies  
> category: PPT

## Question

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.

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.

## In-depth explanation

ICP target under 22 mmHg. CPP target 60-70. After herniation event: continue tier-2 therapies (cooling, barbiturate, paralytics) per neurosurgical guidance.

## Clinical scenario

Pupil now sluggish and 5 mm on the right. ICP 28 mmHg sustained.

## Key concepts

- **Cushing triad** — Hypertension, bradycardia, irregular respirations from severely elevated ICP.
- **hyperosmolar therapy** — Hypertonic saline or mannitol drawing water from brain tissue.
- **cerebral herniation** — Brain displacement past dural folds; emergent decompression required.

## Related questions

- [A nurse is programming a high-alert IV medication on a smart infusion pump. Which actions …](https://mymerci.kr/pages/nclex_q.php?qn_id=372863&lang=en)
- [A patient has a serum potassium of 2.8 mEq/L and a new order for IV potassium chloride 40 …](https://mymerci.kr/pages/nclex_q.php?qn_id=373128&lang=en)
- [A patient on chronic phenytoin for seizure disorder reports new diplopia and unsteady gait…](https://mymerci.kr/pages/nclex_q.php?qn_id=373129&lang=en)
- [A patient on day 2 of total parenteral nutrition (TPN) has a capillary glucose of 248 mg/d…](https://mymerci.kr/pages/nclex_q.php?qn_id=373881&lang=en)
- [A nurse is teaching a patient newly started on metoprolol 25 mg twice daily for hypertensi…](https://mymerci.kr/pages/nclex_q.php?qn_id=374879&lang=en)
- [A patient post-radical cystectomy with ileal conduit urinary diversion is being taught uro…](https://mymerci.kr/pages/nclex_q.php?qn_id=374924&lang=en)
- [A nurse is teaching a patient discharged on oral potassium chloride (extended-release tabl…](https://mymerci.kr/pages/nclex_q.php?qn_id=374939&lang=en)
- [A 72-year-old on chronic warfarin for atrial fibrillation comes for routine follow-up. Aft…](https://mymerci.kr/pages/nclex_q.php?qn_id=374949&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=375148&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=375148&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=375148&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=375148&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=375148&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

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