A 22-year old patient involved in a motorcycle accident has a complete transection of the spinal cord at T-8 resulting in paraplegia. Nursing interventions includes repositioning the patient every 1-2 hours to:
Improve venous circulation and prevent VTE formation
Prevent flexion and contractures of the extremities
Decrease the development of a paralytic ileus
Prevent the development of pressure ulcers
The Correct Answer is D
A. Improve venous circulation and prevent VTE formation. – Incorrect. While repositioning does help with circulation, it is primarily done to prevent pressure injuries.
B. Prevent flexion and contractures of the extremities. – Incorrect. Contracture prevention is important, but passive ROM exercises are more effective for this purpose.
C. Decrease the development of a paralytic ileus. – Incorrect. Paralytic ileus is managed through bowel programs and early mobility, not repositioning alone.
D. Prevent the development of pressure ulcers. – Correct Answer. Paralyzed patients are at high risk for pressure ulcers, especially over bony prominences like the sacrum. Repositioning reduces prolonged pressure, which can lead to skin breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes – These findings indicate improved hydration, resolution of hyperosmolarity, and recovery of neurological function, key markers of HHS improvement.
B. Alert and oriented, balanced intake and output, moist mucous membranes – While improved hydration is good, ketone clearance and hemodynamic stability are more important indicators.
C. Respirations easy and unlabored, eats 50-75% of meals, vital signs stable – Respiratory status is not the primary concern in HHS.
D. Equal intake and output, denies pain or shortness of breath – These signs do not specifically indicate resolution of HHS.
Correct Answer is A
Explanation
A. A child with a sprained wrist is non-infectious and poses no risk to the immunocompromised leukemia patient.
B. Pneumonia is a contagious respiratory infection that poses a high risk.
C. Rheumatic fever can involve post-streptococcal infection risks.
D. A ruptured appendix increases the risk of infection due to peritonitis.
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