The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)

Blood pressure

Bladder function

Heart rate

Reflexes

Respirations

Answer and Explanation

Correct Answer : A,C,E

A. Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations.

B. Bladder function is impacted by spinal cord injuries; however, it is not the initial priority in an emergency setting when life-threatening complications must be managed first.

C. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia.

D. Reflexes are often assessed in cases of spinal injury, but they are not the immediate priority when stabilizing the patient upon arrival.

E. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.

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Correct Answer is B

Explanation

A. Appetite changes are a possible side effect but are not as critical to report immediately.

B. Severe abdominal pain may indicate pancreatitis or liver issues, both serious side effects of valproic acid that require prompt medical attention.

C. Mild indigestion can be a common, non-serious side effect of valproic acid and does not typically require urgent attention.

D. Weight gain is another common side effect of valproic acid but does not necessitate immediate reporting unless it becomes significant.

Correct Answer is ["0.5"]

Explanation

To administer the correct dose of Morphine, the nurse needs to calculate the volume of medication to deliver 1 mg of Morphine. Since the medication is supplied in a concentration of 2 mg per 1 mL, the nurse would administer half of the volume of the vial to provide the ordered 1 mg dose. Therefore, the nurse should administer 0.5 mL of Morphine to the patient.

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The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a patient who is prescribed valproic acid for seizures. The nurse would identify that the patient understands the teaching for the medication when they state, "I will notify my healthcare provider if I experience:

Correct Answer is B

Explanation

A patient is ordered 1 mg of Morphine IV push. The medication is supplied in vials 2 mg/1 mL. What should the nurse administer? (round to the nearest tenth)

Correct Answer is ["0.5"]

Explanation

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