After performing an assessment on a client with a spinal cord injury, which intervention will the nurse employ to prevent cardiovascular complications?
A Sit the client at a 90 degree angle
B Administer 2000 liters of fluid
C Apply compression socks
D Maintain blood pressure exactly at 110/80
The Correct Answer is A
Choice A Rationale: Sitting the client at a 90-degree angle (upright position) helps prevent orthostatic hypotension and cardiovascular complications in clients with spinal cord injuries by improving venous return and cardiac output.
Choice B Rationale: Administering 2000 liters of fluid is an inappropriate intervention, and the volume mentioned is excessive.
Choice C Rationale: Applying compression socks may help prevent deep vein thrombosis (DVT) but does not address cardiovascular complications related to sitting position.
Choice D Rationale: Maintaining blood pressure exactly at 110/80 is not a feasible or appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is A
Explanation
Choice A Rationale: Draining the bladder with a clean intermittent catheter at appropriate intervals is an essential part of managing urinary system complications in clients with spinal cord injury to prevent urinary retention and complications.
Choice B Rationale: Decreasing fluid intake is not typically recommended for individuals with spinal cord injuries, as adequate hydration is important for overall health.
Choice C Rationale: Observing the urine for a foul odor is relevant to monitor for urinary tract infections, but it is not a preventive measure.
Choice D Rationale: Keeping an indwelling catheter in place at all times is not typically recommended due to the increased risk of urinary tract infections and other complications. Clean intermittent catheterization is often preferred.
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