After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?

A Anticipate intubation

B Ask client to cough, then inhale and exhale deeply

C Insert an intravenous catheter

D Administer antihypertensives

Answer and Explanation

The Correct Answer is B

Choice A Rationale: Anticipating intubation is not warranted solely based on an O2 saturation of 92% and without further assessment.

Choice B Rationale: Asking the client to cough, then inhale and exhale deeply is an appropriate initial action to improve oxygenation and assess the client's respiratory status.

Choice C Rationale: Inserting an intravenous catheter is unrelated to the client's O2 saturation and would not address the immediate concern.

Choice D Rationale: Administering antihypertensives is not indicated based on the O2 saturation level, and it may not be safe without further assessment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Rationale: Documenting an overdose is premature without further assessment and evidence.

Choice B Rationale: Acute dementia is not typically diagnosed based on rapidly fluctuating moods alone, and it may not be appropriate for this situation.

Choice C Rationale: While substance abuse comorbidity may be present, it does not fully capture the client's current presentation.

Choice D Rationale: Documenting acute delirium is appropriate in this case. The client's symptoms, including rapidly fluctuating moods and delusions, are indicative of acute delirium, which can be related to substance withdrawal or other medical issues.

A. Weakened gag reflex B. Hyperthermia C. Absence of bowel sounds D. Hypotension E. Polyuria

Correct Answer is ["A","B","D"]

Explanation

Choice A Rationale: A weakened gag reflex is a potential complication of a cervical spinal cord injury and can lead to difficulties in swallowing and increased risk of aspiration.

Choice B Rationale: Hyperthermia can occur as a result of autonomic dysfunction associated with spinal cord injuries, especially when the injury is at a high cervical level.

Choice C Rationale: Absence of bowel sounds is not typically associated with cervical spinal cord injuries but may be seen in lower spinal cord injuries.

Choice D Rationale: Hypotension is a potential complication due to impaired autonomic regulation in cervical spinal cord injuries.

Choice E Rationale: Polyuria is not typically associated with cervical spinal cord injuries but may occur in cases of lower spinal cord injuries affecting bladder function.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

Correct Answer is D

Explanation

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is offering teaching to a caregiver about urinary system complications that occur as a result of spinal cord injury. Which of the following will the nurse include in teaching?

When caring for the client hospitalized with tetanus, which of the following will the nurse include in the care plan?

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize which of the following as confabulation?

A client arrives reporting redness, warmth, and swelling after stepping on a nail one week ago. What is the nurse's priority action?

A nurse is preparing a care plan for a client with a spinal cord injury. Which of the following is the highest priority for the nurse to implement?

After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?

Which of the following manifestations can the nurse expect in a client with upper motor neuron deficit related to a spinal cord injury?

The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?