Trauma Nursing: Head and Spinal Cord Injury · NCLEX Exam

What action should the nurse take if the plateau pressures in a patient on mechanical ventilation for acute TBI are rising above 30 cm H₂O?

  1. No action is needed as this is within the safe range
  2. Notify the provider to adjust ventilation strategy to limit lung injury
  3. Document the value and reassess at the next scheduled check
  4. Increase the tidal volume to lower the airway pressure
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Correct answer: Notify the provider to adjust ventilation strategy to limit lung injury

Plateau pressures above ~30 cm H2O reflect reduced lung compliance and raise the risk of ventilator-associated lung injury, which can worsen outcomes in acute TBI. The nurse should notify the provider so the ventilation strategy can be adjusted.

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