Question

CASE STUDY PROGRESS K.B. has been on the unit for approximately 6 hours. You identify the following changes in your assess- (Pupils Equal, Round, Reactive to Light and Accommodation) is 1+ with slower reaction time than earlier; color is pale, pink, skin is cool and clammy; heart rate is 126 beats/min, respiratory rate is 28 breaths/min, temperature (oral)is 102°F (39"C); Sao, is 90%. You find that neurovascular checks of the affected extrem ities are unchanged. 6. What will your immediate nursing interventions include?

Answer 1

Priority intervention will be the nurse should administer oxygen because her saturation rate is less than normal.then she can do interventiins to manage high pyrexia,