medium · NCLEX-RN Management of Care
The nurse is preparing to assist with the clinical evaluation for neurologic determination of death (brain death testing) in a 29-year-old client who has a severe traumatic brain injury.
Which clinical finding must the nurse report to the provider as a contraindication to proceeding with the formal brain death examination?
- Obtain a bedside blood glucose measurement to rule out hypoglycemia before notifying the team.
- Core body temperature of 34.2 C (93.56 F), for this client at this point in the plan of care.
- Arterial partial pressure of carbon dioxide (PaCO2) of 42 mm Hg (reference range: 35-45 mm Hg).
- Serum sodium level of 149 mEq/L (reference range: 135-145 mEq/L) accompanied by high urine output.
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