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 B
Explanation
A. Allergic – An allergic reaction typically presents with itching, rash, and wheezing rather than fever, chills, and hematuria.
B. Hemolytic – Correct Answer. A hemolytic reaction occurs when the immune system attacks transfused red blood cells due to incompatibility. Symptoms include fever, chills, hypotension, back pain, and hematuria (red-tinged urine). This is a medical emergency requiring immediate intervention.
C. Acute pain – Acute pain transfusion reaction is rare and mainly presents with severe chest, back, and joint pain, without fever or hematuria.
D. Febrile – Febrile reactions cause fever and chills but do not typically cause hematuria, which is indicative of hemolysis.
Correct Answer is C
Explanation
A. Inserting an indwelling urinary catheter – Incorrect. While catheterization may be necessary, it is not the highest priority for an unconscious patient.
B. Putting a nasogastric (NG) tube in place – Incorrect. NG tube placement can be useful for feeding or decompressing the stomach, but airway management takes precedence.
C. Maintaining a patent airway – Correct Answer. Airway patency is the top priority in an unconscious patient to prevent aspiration, hypoxia, or respiratory failure.
D. Administering an enema daily – Incorrect. This is not a priority in unconscious patients.
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