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.

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 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

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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