The client who is unconscious following a fall has a blood pressure of 90/60 mm Hg. The most appropriate action by the nurse is to
A) increase the patient's intravenous (IV) fluids.
B) notify the physician immediately.
C) provide hyperventilation by adjusting ventilator settings.
D) retake the blood pressure in 15 minutes.

Question

Quizplus · Accepted Answer

If the physician has not left orders to treat blood pressure changes, notification must occur if the blood pressure range is less than 100 or more than 150 mm Hg systolic. When a client is hypotensive, cerebral perfusion pressure (CPP) falls and the brain is not adequately perfused. The client needs to be kept in a euvolemic state, so raising the IV fluid rate may not be advisable. Hyperventilation is no longer routinely used; it is used in the setting of herniation to avoid compromising cerebral perfusion. Waiting 15 minutes to retake the blood pressure is too long.

The Client Who Is Unconscious Following a Fall Has a Blood