medium · NCLEX-RN management
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.
Sign up free to see the explanation and track your rank →
More NCLEX-RN management practice
- Which action should the nurse take first?
- Which task is most appropriate to retain and perform solely by the RN?
- Which finding would most likely indicate that the medication is having the intended therap
- Which action must the RN retain rather than delegate to an LPN/VN?
- Which instruction to the AP demonstrates appropriate 'Right Direction and Communication'?
- Which communication from an RN to an AP regarding a client with a urinary catheter is most
- Which action can be delegated to the LPN/VN?
- Which instruction is essential to ensure safety and accuracy?