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The nurse is preparing to turn the patient who sustained a spinal cord injury. How should the nurse proceed?

Use a draw sheet to move the patient

Have the patient grasp the side rail and assist with turning

Cross the lower extremities, turn the hips then turn the shoulders

With one person holding the head, 2 others log roll the client as a unit

Answer and Explanation

The Correct Answer is D

A. Using a draw sheet may cause twisting, which can compromise spinal alignment.

B. Asking the patient to assist may risk further spinal injury.

C. Turning hips and shoulders separately risks disrupting spinal alignment, making this an unsafe approach.

D. Log rolling is the safest way to turn a patient with a spinal cord injury, maintaining spinal alignment and preventing further injury. It requires one person to stabilize the head while others turn the body as a single unit.

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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. Penicillin B. Aminoglycoside C. Fluoroquinolone D. Cephalosporin

Correct Answer is C

Explanation

A. Penicillins are generally safe but are not specific for ototoxicity considerations.

B. Aminoglycosides are avoided in cases of tympanic membrane rupture due to their ototoxic potential, which can lead to hearing loss.

C. Fluoroquinolones, particularly those formulated for otic use, are preferred for tympanic membrane ruptures as they are not ototoxic and are safe for middle ear exposure.

D. Cephalosporins are not typically ototoxic but are less commonly used for tympanic membrane ruptures compared to fluoroquinolones.

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ABG Value	Normal Range
pH	7.35- 7.45
PaCO2	35-45 mm Hg
HCO3	22-25 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

The nurse is preparing to turn the patient who sustained a spinal cord injury. How should the nurse proceed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse anticipates which antibiotic class, due to the lack of ototoxicity, will be ordered for a patient diagnosed with tympanic membrane rupture?

Correct Answer is C

Explanation

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