A nurse prepares to bathe a client with a spinal cord injury. Which of the following is the best first action?
A Unscrew the pins from the cervical tongs
B Ask the client to sit on the edge of the bed
C Gather supplies and at least 3 other people
D Remove the straps from the halo vest
The Correct Answer is C
Choice A Rationale: Unscrewing the pins from the cervical tongs is not the best first action for bathing a client with a spinal cord injury.
Choice B Rationale: Asking the client to sit on the edge of the bed may not be appropriate or safe without proper assistance and equipment.
Choice C Rationale: The best first action is to gather supplies and at least 3 other people. Bathing a client with a spinal cord injury can be complex and may require additional assistance for safety and comfort.
Choice D Rationale: Removing the straps from the halo vest is not the first step in the bathing process and may not be necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.
Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.
Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.
Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.
Correct Answer is C
Explanation
Choice A Rationale: Repositioning may be important for preventing complications, but it does not explain the pain described by the client.
Choice B Rationale: A continual inflammatory process is not typically the cause of the pain described by the client with a spinal cord injury.
Choice C Rationale: Nerve damage in the spinal cord is a common cause of neuropathic pain with these characteristics.
Choice D Rationale: Telling the client that the pain will go away in 2 weeks without further assessment or explanation is not accurate and may raise unrealistic expectations.
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