The client with a head injury has multiple nursing needs. To promote venous drainage and alleviate pressure, the nurse should:
A)
encourage the client to cough.
B)
elevate the head of the bed 30 degrees.
C)
use oxygen at 2 L/min.
D)
monitor the temperature every 15 minutes.
B
Explanation:
A)
Elevation of 30 degrees promotes venous drainage. Coughing would increase ICP. Oxygen is given at a rate to maintain saturation of 94% or better. Temperature should be monitored every 2 hours.
Application
Implementation
Physiological Integrity: Reduction of Risk Potential
B)
Elevation of 30 degrees promotes venous drainage. Coughing would increase ICP. Oxygen is given at a rate to maintain saturation of 94% or better. Temperature should be monitored every 2 hours.
Application
Implementation
Physiological Integrity: Reduction of Risk Potential
C)
Elevation of 30 degrees promotes venous drainage. Coughing would increase ICP. Oxygen is given at a rate to maintain saturation of 94% or better. Temperature should be monitored every 2 hours.
Application
Implementation
Physiological Integrity: Reduction of Risk Potential
D)
Elevation of 30 degrees promotes venous drainage. Coughing would increase ICP. Oxygen is given at a rate to maintain saturation of 94% or better. Temperature should be monitored every 2 hours.
Application
Implementation
Physiological Integrity: Reduction of Risk Potential
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