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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

A. Instill anesthetic eye drops in both eyes B. Perform a visual acuity exam C. Determine the pH of the chemical splash D. Irrigate both eyes with normal saline

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Correct Answer is A

Explanation

The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?

Correct Answer is D

Explanation

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