The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?
Frequent passive range of motion
Coughing and deep breathing exercises once per shift
Turn patient every 4 hours
Ambulate patient twice per shift
The Correct Answer is A
A. Frequent passive range of motion exercises are crucial for preventing complications of immobility, such as contractures and pressure ulcers, and to promote circulation in patients with spinal cord injuries.
B. While coughing and deep breathing exercises are important for respiratory health, they should be performed more frequently than once per shift in patients with reduced mobility to prevent respiratory complications.
C. Turning the patient every 4 hours may not be adequate to prevent pressure ulcers; typically, patients should be turned at least every 2 hours.
D. Patients with a complete spinal cord injury at C7 typically lack the ability to ambulate, making this intervention inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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 D
Explanation
A. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.
B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.
C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.
D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.
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