The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage.The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg,heart rate 110 beats/min,respiratory rate 20 breaths/min,oxygen saturation (SpO₂)95% on 3 L/min oxygen via nasal cannula,and a temperature of 101.5° F.Which physician order should the nurse institute first? A) Blood cultures (2 specimens) for temperature 101° F B) Acetaminophen (Tylenol) 650 mg per rectum C) 500 mL albumin infusion intravenously D) Decadron 20 mg intravenous push every 4 hours

Question

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage.The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg,heart rate 110 beats/min,respiratory rate 20 breaths/min,oxygen saturation (SpO₂)95% on 3 L/min oxygen via nasal cannula,and a temperature of 101.5° F.Which physician order should the nurse institute first? A) Blood cultures (2 specimens) for temperature > 101° F B) Acetaminophen (Tylenol) 650 mg per rectum C) 500 mL albumin infusion intravenously D) Decadron 20 mg intravenous push every 4 hours

Quizplus · Accepted Answer

Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage.Once an aneurysm has been repaired surgically,blood pressure is allowed to rise to prevent vasospasm.Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion.Blood cultures,acetaminophen administration,and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.

The Nurse Is Caring for a Patient 5 Days Following