The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the patient's respiratory effort has increased. What is the nurse's most appropriate response?
A) Inform the care team and assess for further signs of possible increased ICP.
B) Administer bronchodilators as ordered and monitor the patient's LOC.
C) Increase the patient's bed height and reassess in 30 minutes.
D) Administer a bolus of normal saline as ordered.
Ans: A
Feedback:
Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly informed. A bolus of IV fluid will not address the problem. Repositioning the patient and administering bronchodilators are insufficient responses, even though these actions may later be ordered.
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