The nurse is suctioning a client with a traumatic head injury and notes that the intracranial pressure has increased from 14 to 16 mm Hg. Which of the following actions should the nurse take first?
A)Document the increase in intracranial pressure.
B)Assure that the client's neck is not in a flexed position.
C)Notify the health care provider about the change in pressure.
D)Increase the rate of the prescribed propofol infusion.

Question

Quizplus · Accepted Answer

Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the client for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning.
Propofol is used to control client anxiety or agitation; there is no indication that anxiety has contributed to the increase in intracranial pressure.

The Nurse Is Suctioning a Client with a Traumatic Head