A 22-year old patient involved in a motorcycle accident has a complete transection of the spinal cord at T-8 resulting in paraplegia. Nursing interventions includes repositioning the patient every 1-2 hours to:
Improve venous circulation and prevent VTE formation
Prevent flexion and contractures of the extremities
Decrease the development of a paralytic ileus
Prevent the development of pressure ulcers
The Correct Answer is D
A. Improve venous circulation and prevent VTE formation. – Incorrect. While repositioning does help with circulation, it is primarily done to prevent pressure injuries.
B. Prevent flexion and contractures of the extremities. – Incorrect. Contracture prevention is important, but passive ROM exercises are more effective for this purpose.
C. Decrease the development of a paralytic ileus. – Incorrect. Paralytic ileus is managed through bowel programs and early mobility, not repositioning alone.
D. Prevent the development of pressure ulcers. – Correct Answer. Paralyzed patients are at high risk for pressure ulcers, especially over bony prominences like the sacrum. Repositioning reduces prolonged pressure, which can lead to skin breakdown.
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Related Questions
Correct Answer is D
Explanation
A. Bring fresh-cut flowers to cheer the patient up. – Incorrect. Fresh flowers should be avoided due to the risk of fungal or bacterial infections in immunocompromised patients.
B. Take the patient to the cafeteria for meals. – Incorrect. Bone marrow transplant patients are at high risk for infection, and leaving the room increases exposure to pathogens.
C. A cover gown is not necessary when entering the patient’s room. – Incorrect. Depending on the hospital’s isolation precautions, visitors may be required to wear gowns and masks to protect the patient.
D. Do not visit if you have had a recent infection. – Correct Answer. Even mild infections can be life-threatening to patients undergoing a bone marrow transplant, so visitors should stay away if they are unwell.
Correct Answer is C
Explanation
A. Incorrect. Blood verification must be done by two licensed nurses.
B. Incorrect. Monitoring for transfusion reactions is the nurse's responsibility.
C. Correct. UAPs can obtain baseline vital signs before the transfusion, as long as the nurse interprets them.
D. Incorrect. Verifying patient ID for blood transfusions is a nursing responsibility per hospital protocol.
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