Question

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

A. Maintain a PaCO2 of approximately 35 mm Hg.
B. Provide small doses of fentanyl via IV bolus for pain management.
C. Monitor body temperature every 1 to 2 hr.
D. Reposition the client every 2 hr.

Answer 1

The nurse's priority intervention is to maintain a PaCO2 level of approximately 35 mm Hg.

Step-by-step explanation:

The nurse's priority intervention for a client with a closed head injury and receiving mechanical ventilation is to maintain a PaCO2 of approximately 35 mm Hg.

PaCO2 refers to the partial pressure of carbon dioxide in the arterial blood. In a closed head injury, elevated PaCO2 can lead to increased intracranial pressure, which can worsen the patient's condition.

Other interventions mentioned in the options are important, but maintaining a proper PaCO2 level is the priority.