The arterial blood gas (ABG) report of a patient with a spinal cord injury indicates hypoxia. Select two interventions the nurse would perform to improve the patient's respiratory status.
Perform assisted coughing.
Administer steroids.
Administer oxygen.
Administer antibiotic drugs.
Correct Answer : A,C
Choice A reason: Performing assisted coughing is crucial for patients with spinal cord injuries who may have weakened respiratory muscles. Assisted coughing helps clear secretions from the airways, thus improving oxygenation and preventing respiratory complications like pneumonia.
Choice B reason: Administering steroids is not a primary intervention for addressing hypoxia in patients with spinal cord injuries. Steroids can be used to reduce inflammation, but they do not directly improve respiratory status or oxygenation.
Choice C reason: Administering oxygen is a direct and effective intervention for managing hypoxia. Supplemental oxygen helps ensure that the patient maintains adequate blood oxygen levels, which is critical for overall tissue perfusion and function.
Choice D reason: Administering antibiotics is not immediately relevant to the treatment of hypoxia unless there is an underlying infection causing or contributing to respiratory distress. Antibiotics are used to treat infections, not directly to improve respiratory status in cases of hypoxia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Asking the patient to try bearing weight on the injured ankle is not appropriate at this stage. Bearing weight can cause further injury or exacerbate the swelling and pain. The initial treatment should focus on reducing swelling and providing support.
Choice B reason: Elevating the ankle above heart level is appropriate because it helps to reduce swelling by promoting venous return and decreasing fluid accumulation in the affected area. Elevation is a standard first aid measure for managing acute injuries and swelling.
Choice C reason: Applying a warm moist pack to the ankle is not advisable immediately after an injury. In the acute phase, cold therapy (ice) is recommended to reduce swelling and pain. Warm therapy is more appropriate during the recovery phase, once swelling has subsided.
Choice D reason: Assessing the ankle's passive range of motion (ROM) may be necessary later, but not immediately upon arrival. The priority is to manage pain and swelling first. ROM assessments can be painful and might worsen the injury if conducted too soon.
Correct Answer is B
Explanation
Choice A reason: Asking the patient about loose stools is important as it can help identify possible causes of fluid and electrolyte imbalances. However, this question alone would not be the immediate or primary action to take in response to generalized weakness.
Choice B reason: Suggesting that the healthcare provider order a basic metabolic panel is the most appropriate action. Potassium-wasting diuretics can lead to hypokalemia, which can cause symptoms like generalized weakness. A basic metabolic panel will provide information on the patient's electrolyte levels, including potassium, and help determine if the weakness is due to an electrolyte imbalance. This allows for appropriate intervention to correct the imbalance and prevent further complications.
Choice C reason: Assessing for facial muscle spasms is relevant because hypokalemia can cause muscle cramps and spasms. However, it does not address the root cause of the weakness and does not lead to immediate intervention.
Choice D reason: Calling for a rapid response team is generally reserved for situations where the patient is experiencing acute, life-threatening symptoms requiring immediate intervention. Generalized weakness in the context of a patient on a potassium-wasting diuretic does not usually necessitate such an urgent response unless it progresses to more severe symptoms.
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