A patient is admitted to the emergency department with a spinal cord injury at the level of T2 following a traumatic fall from a roof. Which finding is of most concern to the nurse?

Heart rate of 45 beats/min

SpO2 of 91%

Blood pressure of 98/62 mmHg

Loss of motor and sensory function in extremities

Answer and Explanation

The Correct Answer is A

Choice A reason:

A heart rate of 45 beats/min (bradycardia) is concerning because it indicates a significant impact on the autonomic nervous system, which can occur with high thoracic spinal cord injuries. Bradycardia can lead to inadequate cardiac output and may require immediate intervention to prevent further cardiovascular compromise.

Choice B reason:

An SpO2 of 91% is slightly below normal but not immediately life-threatening. While monitoring and addressing oxygen saturation is important, it is not as critical as the hemodynamic instability indicated by bradycardia in this context.

Choice C reason:

A blood pressure of 98/62 mmHg is on the lower end of the normal range but not immediately alarming. While hypotension is a concern in spinal cord injury patients, the more pressing issue in this scenario is the bradycardia, which can have more immediate and severe consequences.

Choice D reason:

Loss of motor and sensory function in the extremities is a significant finding in spinal cord injuries and indicates the level and severity of the injury. However, it is not immediately life-threatening and does not require as urgent intervention as bradycardia in this acute setting.

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Correct Answer is C

Explanation

Choice A reason:

The application of PEEP does not inherently increase the need for FiO2 (fraction of inspired oxygen) administration. PEEP helps improve oxygenation, potentially reducing the need for higher FiO2 levels.

Choice B reason:

While PEEP can contribute to better lung inflation by keeping the alveoli open, this is a secondary effect. The primary goal of PEEP is to prevent alveolar collapse at the end of expiration.

Choice C reason:

PEEP prevents alveolar collapse during expiration, which is its primary therapeutic effect. By maintaining a certain level of pressure in the lungs at the end of expiration, PEEP ensures that the alveoli remain open, improving gas exchange and oxygenation.

Choice D reason:

Although PEEP can help reduce the risk of atelectasis (collapse of part or all of a lung), it does not directly prevent barotrauma. Barotrauma is related to high airway pressures, and careful monitoring of ventilator settings is necessary to avoid it.

A. Temperature of 96.8°F B. Blood pressure 110/68 C. Respiratory rate of 20 breaths/min D. Heart rate of 70 beats/min

Correct Answer is B

Explanation

Choice A reason:

A temperature of 96.8°F is within the normal range for a human body (97.8°F to 99.1°F). However, it does not necessarily indicate the desired effect of Dopamine. Dopamine is primarily used to improve blood flow and cardiac output, particularly in critically ill patients. Therefore, temperature alone is not a reliable indicator of its effectiveness.

Choice B reason:

Blood pressure of 110/68 mmHg suggests that the Dopamine is effectively maintaining the patient's hemodynamic stability. Dopamine is often used to support blood pressure in patients with hypotension, particularly after spinal cord injuries. Maintaining an adequate blood pressure ensures that vital organs receive sufficient blood flow, which is a key therapeutic goal of Dopamine administration.

Choice C reason:

A respiratory rate of 20 breaths/min is considered normal for an adult (12-20 breaths/min). While normal respiratory rate is a positive sign, it is not a direct measure of Dopamine's effectiveness. Dopamine's primary action is on the cardiovascular system, so a normal respiratory rate alone does not necessarily indicate that the drug is having the desired effect.

Choice D reason:

A heart rate of 70 beats/min is within the normal range for adults (60-100 beats/min). Similar to the respiratory rate, while a normal heart rate is beneficial, it is not a direct indicator of Dopamine's effectiveness. Dopamine's role in improving cardiac output and blood pressure is more critical in assessing its desired effects.

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A patient is admitted to the emergency department with a spinal cord injury at the level of T2 following a traumatic fall from a roof. Which finding is of most concern to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

Correct Answer is C

Explanation

The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

Correct Answer is B

Explanation

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