The Nurse Is Caring for a Patient Who Sustained a Moderate

Multiple Choice

The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response?

A) Inform the care team and assess for further signs of possible increased ICP.
B) Administer bronchodilators as ordered and monitor the patients LOC.
C) Increase the patients bed height and reassess in 30 minutes.
D) Administer a bolus of normal saline as ordered.