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    Ati nur 250 med surg proctored exam(clinical nursing practicum)
    Select All That Apply

    A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse plan to include in the plan of care?(Select All that Apply.)

    Explanation & Rationale

    A. Monitoring volume status Maintaining adequate fluid balance prevents hypotension and cerebral hypoperfusion, which can worsen ICP. B. Ensuring proper ventriculostomy transducer levels Accurate positioning of the transducer at the level of the foramen of Monro (tragus of the ear) ensures valid ICP readings. C. Managing sedation Sedation can reduce cerebral metabolism and help control ICP, especially in agitated patients. D. Completing hourly endotracheal suctioning Frequent suctioning increases ICP and should only be done as needed with pre-oxygenation. E. Elevating the head of the bed 15° The head of the bed should be elevated 30° (not 15°) to promote venous drainage from the brain and reduce ICP.

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