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The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

Padded tongue blades to prevent injury in the event of seizure

Soft wrist restraints to prevent injury

Ambu bag and oxygen connection for respiratory distress

Wrenches for emergency removal of traction equipment

Oral suction tube (Yankaur) for secretion removal

Answer and Explanation

Correct Answer : C,D,E

A. Padded tongue blades are not appropriate for seizure management and are not necessary in this context.

B. Soft wrist restraints are not required in this scenario unless otherwise indicated.

C. An Ambu bag and oxygen are crucial for respiratory support, especially if the patient has compromised breathing due to spinal cord injury.

D. Wrenches should be readily available to quickly remove halo traction in case of an emergency, such as if the patient's airway needs to be accessed.

E. An oral suction tube (Yankauer) is important for managing oral secretions, which can be challenging for patients with limited mobility.

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Correct Answer is D

Explanation

A. Antibiotics may be necessary if infection is confirmed, but this is not the priority action.

B. Applying a pressure dressing could increase intracranial pressure or worsen the injury.

C. IV fluids can be helpful in managing shock but are not directly related to CSF leakage management.

D. Yellowish fluid from the ear, which creates a "halo" or yellow ring around it on gauze, may indicate cerebrospinal fluid (CSF) leakage. This is a sign of a potential skull fracture and requires prompt provider notification. Allowing the fluid to drain and collecting it can provide necessary information about the injury.

A. Take this medication with food or milk B. Get potassium levels drawn periodically C. Increase intake of green vegetables D. Use salt substitute for cooking

Correct Answer is B

Explanation

A. While taking some medications with food or milk can help with absorption, this is not a specific requirement for lisinopril.

B. Lisinopril, an ACE inhibitor, can lead to elevated potassium levels. Periodic monitoring of potassium levels is essential to prevent hyperkalemia, a potentially dangerous side effect.

C. Increasing intake of green vegetables is generally healthy but does not directly impact lisinopril's effects.

D. Many salt substitutes contain potassium, which could elevate potassium levels further when taken with ACE inhibitors like lisinopril, posing a risk for hyperkalemia.

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The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

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The nurse is caring for a trauma patient with suspected brain injury. The nurse notices a yellow stain around fluid dripping from the patient's ear. The nurse's priority intervention will be as follows:

Correct Answer is D

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Correct Answer is B

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