Which action should the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Cardiac monitoring for bradycardia

Administration of low-molecular-weight heparin

Assessment of respiratory rate and effort

Application of pneumatic compression devices to legs

Answer and Explanation

The Correct Answer is C

A. Cardiac monitoring for bradycardia: While cardiac changes can occur with spinal cord injury, respiratory complications are more common and pose a greater immediate threat to the patient's well-being. Therefore, assessing respiratory status takes priority over cardiac monitoring in this situation.

B. Administration of low-molecular-weight heparin: Venous thromboembolism prophylaxis is important for patients with spinal cord injury, but it is not the highest priority within the first 16 hours of admission. Respiratory assessment is more critical for immediate patient safety.

C. Assessment of respiratory rate and effort: Respiratory complications, such as impaired breathing or respiratory failure, are common in patients with spinal cord injury, particularly at the C5 level, which affects the diaphragm and intercostal muscles. Early detection of respiratory distress is crucial for timely intervention to prevent respiratory compromise.

D. Application of pneumatic compression devices to legs: Pneumatic compression devices are used for preventing venous thromboembolism, but they do not address the immediate priority of assessing and managing respiratory status in a patient with spinal cord injury.

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Correct Answer is ["A","E","F"]

Explanation

A. Suction Tubing: This equipment is necessary for clearing the patient's airway in case of any secretions or vomitus that could obstruct breathing following a seizure episode.

B. Nasogastric Tube: While nasogastric tubes may be necessary in some medical conditions, they are not typically indicated following treatment for status epilepticus unless there are specific concerns related to the patient's condition that require gastric decompression or feeding.

C. Urinary Catheter: While urinary catheters may be used in some cases, they are not routinely required following treatment for status epilepticus unless there are specific concerns about urinary retention or monitoring of urine output.

D. Tongue Blade: Tongue blades are not typically necessary following treatment for status epilepticus. They may pose a risk of injury to the patient if used unnecessarily.

E. Oxygen Mask: Oxygen masks are essential for providing supplemental oxygen to the patient, especially if there are concerns about hypoxia following a seizure episode.

F. Side Rail Pad: Side rail pads are important for preventing injury to the patient during postictal confusion or agitation. They help to protect the patient from accidentally falling out of bed or injuring themselves against the bed rails.

A. Call the health care provider if stools are tarry. B. Clopidogrel will reduce cerebral artery plaque formation. C. Clopidogrel will dissolve clots in the cerebral arteries. D. Monitor and record the blood pressure daily.

Correct Answer is B

Explanation

A. Call the health care provider if stools are tarry: This instruction is more relevant to medications such as aspirin or NSAIDs, which can increase the risk of gastrointestinal bleeding.
Clopidogrel, while also an antiplatelet medication, is less likely to cause gastrointestinal bleeding compared to aspirin.

B. Clopidogrel will reduce cerebral artery plaque formation: Clopidogrel is an antiplatelet
medication that inhibits platelet aggregation, thereby reducing the formation of blood clots and potentially slowing the progression of atherosclerosis by preventing further plaque formation.

C. Clopidogrel will dissolve clots in the cerebral arteries: While clopidogrel can help prevent the formation of new clots, it does not actively dissolve existing clots in the cerebral arteries. Its primary mechanism of action is to inhibit platelet aggregation and prevent clot formation.

D. Monitor and record the blood pressure daily: While monitoring blood pressure is important for managing cerebral atherosclerosis and reducing the risk of stroke, it is not directly related to the action of clopidogrel. Blood pressure management may involve lifestyle modifications and other medications but is not specific to clopidogrel administration.

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Which action should the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply.)

Correct Answer is ["A","E","F"]

Explanation

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel?

Correct Answer is B

Explanation

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)