Med/surg 2: Exam 2 Study Guide (Latest 2024 / 2025 )

A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO2 of 33 mm Hg. What action is most important for the nurse to take? 1. Encourage the client to slow the breathing rate. 2. Auscultate the client's lungs and suction if indicated. 3. Advise the healthcare provider that the client needs supplemental oxygen. 4. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure {Ans: 4. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure A lower than expected PCO2 actually will benefit the client because it reduces intracranial pressure by preventing cerebral vasodilation; the results should be reported, and monitoring for signs and symptoms of increased intracranial pressure [1] [2] should continue (restlessness, confusion and lethargy, pupillary and oculomotor dysfunction, hemiparesis or hemiplegia of the contralateral side, projectile vomiting without nausea, increased systolic pressure, widening pulse pressure and bradycardia, and altered breathing pattern). Instructing the client to slow the breathing rate is inappropriate because it will elevate the PCO2, which will increase intracranial pressure. There is no