When planning care for a client with a C3 spinal cord injury, which of the following will the nurse identify as the priority ongoing assessment?

A Urinary output

B Blood Pressure

C Counting respirations

D Bowel sounds

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Urinary output is also an important assessment in clients with a C3 spinal cord injury because it helps monitor for urinary retention and potential complications but it is not a priority compared to assessing the respiratory function of this client.

Choice B Rationale: Blood pressure is important to monitor but may not be the top priority assessment in this context.

Choice C Rationale: The nurse should prioritize counting respirations for a client with a C3 spinal cord injury, as this level of injury affects the phrenic nerve that innervates the diaphragm. The client may have difficulty breathing and require mechanical ventilation.

Choice D Rationale: Bowel sounds are important but may not be the priority assessment in this case.

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Correct Answer is C

Explanation

Choice A Rationale: Notifying the nurse administrator should not be the first action when a client is experiencing pain or injury.

Choice B Rationale: Cleaning up the spill is important to prevent further accidents but does not address the client's immediate pain and discomfort.

Choice C Rationale: Asking the client to remain still is the best first action to ensure the client's safety and assess the extent of the injury or pain.

Choice D Rationale: Documenting the incident is important but should follow

A. A measure the calves for symmetry B. B palpate the bladder C. C Place a pillow between the knees and ankles D. D Check the gag reflex

Correct Answer is C

Explanation

Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.

Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.

Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.

Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.

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When planning care for a client with a C3 spinal cord injury, which of the following will the nurse identify as the priority ongoing assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client complains of back pain after slipping and falling on a wet floor at the hospital. What is the nurses best first action to take?

Correct Answer is C

Explanation

A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

Correct Answer is C

Explanation

When planning care for a client with a C3 spinal cord injury, which of the following will the nurse identify as the priority ongoing assessment?

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