NCLEX-RN

Answer: A - The best action of the nurse is to suction the client briefly and gently to remove accumulated secretions in the lungs and airway passages. Gentle suctioning, lasting for no more than 15 seconds, is required to avoid a sudden increase in intracranial pressure. Instructions on deep breathing exercises should have been given prior to surgery for better reception. The maximum elevation of the head of the bed should be 20 to 30 degrees to allow drainage of CSF, avoid increased ICP, and facilitate better ventilation.