- increase the rate of the sedative IV drip.
- chart the findings and continue to monitor the client.
- reposition the client.
- contact the physician.
An ICU nurse monitors a client recovering from a head injury. The client’s intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client’s endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
Number 2 is correct.
Rationale: Intracranial pressure can increase with suctioning or repositioning the client, and a temporary jump in ICP is expected in these situations. If the ICP returns to normal, no further intervention is needed, and the nurse should chart the findings and continue to monitor the client.