The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3.Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg,heart rate 55 beats/min,respiratory rate 10 breaths/min,oxygen saturation (SpO₂)94% on oxygen at 3 L per nasal cannula.What is the priority nursing action? A) Monitor the patient's airway patency. B) Elevate the head of the patient's bed. C) Increase supplemental oxygen delivery. D) Support bony prominences with padding.

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A GCS score of 3 is indicative of a deep coma.Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3,the nurse must focus on maintaining the patient's airway.There is no evidence to support the need for increased supplemental oxygen.A respiratory rate of 10 breaths/min may result in increased CO₂ retention,which may further increase ICP through dilatation of cerebral vessels.Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however,airway patency is the immediate priority.

The Nurse Assesses a Patient with a Skull Fracture to Have