A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

Assess the level at which the client has intact sensation

Determine the level at which the client has retained mobility

Monitor respiratory effort and oxygen saturation level

Check the blood pressure and pulse for signs of spinal shock

Answer and Explanation

The Correct Answer is C

Choice A reason:

Assessing the level at which the client has intact sensation is important in the overall management of a spinal cord injury. However, it is not the immediate priority in an emergency setting. Ensuring the client's respiratory function and oxygenation is the first concern to stabilize the patient.

Choice B reason:

Determining the level at which the client has retained mobility is part of the assessment of a spinal cord injury but is secondary to monitoring and ensuring adequate respiratory effort and oxygen saturation. Mobility can be evaluated once the patient's vital signs are stable.

Choice C reason:

Monitoring respiratory effort and oxygen saturation level is the priority nursing action for a client with a spinal cord injury at the C3 to C4 level. Injuries at this level can impair the diaphragm and other muscles essential for breathing. Ensuring that the patient has adequate respiratory function and oxygenation is critical to prevent respiratory failure.

Choice D reason:

Checking blood pressure and pulse for signs of spinal shock is important, but the immediate priority is to ensure that the patient is breathing effectively and has sufficient oxygen saturation. Respiratory compromise can occur quickly with high-level spinal cord injuries, making it the most urgent concern.

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Correct Answer is D

Explanation

Choice A reason:

Mechanical ventilation is not typically required for patients with rib fractures unless there is severe respiratory compromise or other underlying issues that necessitate ventilatory support.

Choice B reason:

Preparing for a chest tube is not generally required for isolated rib fractures unless there is an associated pneumothorax or hemothorax. Chest tubes are used to manage complications that involve air or blood in the pleural space.

Choice C reason:

Needle decompression is performed in emergencies to relieve tension pneumothorax. This procedure is not indicated for simple rib fractures without evidence of a tension pneumothorax.

Choice D reason:

An intercostal nerve block for pain management is an appropriate intervention for a patient with rib fractures. It helps control pain, allowing the patient to breathe deeply and cough effectively, which is important for preventing complications such as pneumonia.

A. Use non-steroidal anti-inflammatory drugs for discomfort. B. Limit sodium in the diet to 3.5 g/day. C. Place client in a lateral position. D. Limit fluid intake to 2 liters/day.

Correct Answer is D

Explanation

Choice A reason:

Using non-steroidal anti-inflammatory drugs (NSAIDs) for discomfort is not recommended for patients with heart failure because NSAIDs can cause fluid retention and worsen heart failure symptoms. They can also interfere with the effects of certain heart failure medications.

Choice B reason:

Limiting sodium in the diet to 3.5 g/day is not restrictive enough for heart failure patients. Typically, heart failure management involves reducing sodium intake to around 2-2.3 g/day to help prevent fluid retention and reduce the workload on the heart.

Choice C reason:

Placing the client in a lateral position is not specifically beneficial in the management of heart failure. While changing positions can be part of general patient care, it does not directly address the fluid balance or cardiac workload in heart failure patients.

Choice D reason:

Limiting fluid intake to 2 liters/day is a common intervention for managing heart failure. This helps to prevent fluid overload, which can exacerbate heart failure symptoms and lead to complications such as pulmonary edema. Maintaining a careful balance of fluid intake is essential for managing heart failure effectively.

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A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

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