A nurse is caring for a client who experienced severe head trauma.
The client's partner asks the nurse why they are concerned about the mean arterial pressure (MAP). The nurse should explain that MAP determines which of the following?

Choice A rationale

Quadriplegia, also known as tetraplegia, involves paralysis affecting all four limbs and the torso. This typically results from spinal cord injuries at the cervical level (C1-C8), as these segments innervate the diaphragm and upper and lower extremities. A T2-T3 injury is lower in the spinal column and would not result in paralysis of all four limbs, as motor control of the upper limbs originates from cervical segments.

Choice B rationale

Paresthesia refers to an abnormal sensation, such as tingling, numbness, or "pins and needles," often caused by nerve damage or compression. While paresthesia can be a symptom of a spinal cord injury, it describes a sensory deficit rather than the primary type of motor disability. A T2-T3 injury causes a specific pattern of motor and sensory loss below the level of injury, which is a broader classification.

Choice C rationale

Paraplegia is paralysis that primarily affects the lower half of the body, including the legs and, depending on the level, parts of the trunk. A spinal cord injury at the T2-T3 vertebral level is located in the thoracic region, below the cervical innervation for the upper extremities. Therefore, motor and sensory deficits would predominantly manifest in the lower limbs and trunk, consistent with paraplegia.

Choice D rationale

Hemiplegia is paralysis affecting one side of the body, typically resulting from brain injuries such as stroke, which affect motor pathways contralaterally. It is not characteristic of spinal cord injuries, where neurological deficits are typically bilateral below the level of the lesion due to the organization of descending motor tracts within the spinal cord.

Choice A rationale

Checking the expiration date with a second nurse is a critical safety measure, ensuring proper identification and viability of the blood product. This dual verification mitigates the risk of administering expired or incorrect blood, which could lead to severe immunological reactions such as acute hemolytic transfusion reactions due to complement activation and antigen-antibody complex formation. This adherence to protocol aligns with best practices for patient safety.

Choice B rationale

Priming blood tubing with dextrose 5% in water is contraindicated because dextrose solutions are hypotonic and can cause hemolysis of red blood cells. The osmotic gradient draws water into the erythrocytes, leading to cell lysis and the release of hemoglobin, which can result in renal damage and hyperkalemia. Normal saline (0.9% sodium chloride) is isotonic and is the only solution compatible for priming blood transfusion sets to maintain red blood cell integrity.

Choice C rationale

Inserting an IV with a 20-gauge or larger needle (e.g., 18-gauge) is recommended for blood transfusions. This larger bore minimizes shear stress on red blood cells during infusion, reducing the risk of hemolysis. Smaller gauges can cause mechanical trauma to the fragile erythrocytes as they pass through, potentially leading to the release of intracellular contents and adverse patient reactions.

Choice D rationale

Transfusing a blood product within 4 hours, not 5 hours, after removing it from refrigeration is the standard guideline. Exceeding this timeframe increases the risk of bacterial proliferation within the blood product, as temperatures rise above refrigeration levels. This can lead to severe febrile non-hemolytic transfusion reactions or even septic shock, compromising patient safety and treatment efficacy.

Choice E rationale

Checking vital signs before transfusion establishes a baseline for the client's physiological status. This baseline is essential for detecting early signs of transfusion reactions, such as fever, chills, or changes in blood pressure. Significant deviations from baseline vital signs during or after the transfusion indicate a potential adverse event, necessitating immediate intervention to ensure patient safety.