medium · NCLEX-RN Management of Care

The charge nurse in the neurological intensive care unit is dividing care responsibilities for a client who is being evaluated for neurologic determination of death (brain death). The client is currently hemodynamically stable on a mechanical ventilator.

Which clinical responsibility must the registered nurse (RN) retain?

  1. Transporting a labeled arterial blood gas specimen immediately to the laboratory tube system, for this client.
  2. Obtaining a baseline 12-lead electrocardiogram (ECG) using the bedside machine.
  3. Recording the exact hourly urine output from the client's indwelling urinary catheter, for this client.
  4. Assessing the client for the bilateral absence of pupillary, corneal, oculovestibular, and gag reflexes.

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