Question

A nurse is planning care for a client who has. closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurses priority?

a.Maintain a PaCO2 of approximately 35 mm Hg.
b.Provide small doses of fentanyl via IV bolus for pain management.
c.Measure body temperature every 1 to 2 hr.
d.Reposition the client every 2 hr.

Answer 1

The nurse's priority for a client with a closed traumatic brain injury on mechanical ventilation is to maintain a PaCO2 of approximately 35 mm Hg due to its impact on intracranial pressure.

Step-by-step explanation:

The nurse's priority when caring for a client with a closed traumatic brain injury receiving mechanical ventilation is to maintain a PaCO2 of approximately 35 mm Hg. This is crucial because the level of carbon dioxide in the blood can affect intracranial pressure, which is a significant concern after a brain injury. Excessive carbon dioxide can lead to increased intracranial pressure, potentially worsening the brain injury or causing additional damage. Therefore, monitoring and managing PaCO2 takes precedence over pain management, temperature checks, and repositioning in this particular scenario.