A newly admitted critical head injury client presents to the neuro-ICU. The client is unresponsive to painful stimuli but able to breathe on his own. As the shift progresses, the nurses note a decrease in the client's respiratory effort
The client cannot maintain his O2 saturation above 70%. The nurses should anticipate assisting in beginning what type of pulmonary support?
A) Increase oxygen level to 10 L/min.
B) Begin Bi-PAP.
C) Call respiratory therapy to suction the client.
D) Prepare for mechanical ventilation.
Ans: D
Feedback:
When alveolar ventilation is inadequate to maintain PO2 or PCO2 levels because of respiratory or neurologic failure, mechanical ventilation may be lifesaving. Usually a nasotracheal, orotracheal, or tracheotomy tube is inserted into the trachea to provide the client with the airway needed for mechanical ventilation.
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