A nurse is caring for a client who was brought to the emergency department (ED) by EMS after diving into a lake and losing consciousness. The client was intubated in the field by the paramedics. A CT of the head and neck revealed a spinal cord injury at the level of C3-4. What is the priority nursing action?
Maintain the cervical collar in place.
Ask the client if they remember any events around the time of the injury.
Explain to the client that they will never be able to walk again.
Notify the client's parents that they are in the ED.
The Correct Answer is A
Choice A Reason:
Maintaining the cervical collar in place is crucial for a client with a spinal cord injury at the level of C3-4. This action prevents further damage to the spinal cord by immobilizing the neck and maintaining proper alignment. Any movement could exacerbate the injury, potentially leading to more severe neurological deficits or even paralysis.
Choice B Reason:
Asking the client if they remember any events around the time of the injury is not the priority in this situation. While obtaining a history is important, it should not take precedence over stabilizing the spinal cord to prevent further injury. The primary focus should be on ensuring the client's safety and preventing additional harm.
Choice C Reason:
Explaining to the client that they will never be able to walk again is inappropriate and premature. The prognosis for spinal cord injuries can vary widely, and it is essential to provide accurate information based on a thorough assessment and consultation with specialists. Additionally, delivering such news requires sensitivity and should be done in a supportive manner.
Choice D Reason:
Notifying the client's parents that they are in the ED is important for family communication and support. However, it is not the immediate priority. The primary focus should be on stabilizing the client's condition and preventing further injury. Once the client is stabilized, the nurse can then inform the family.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
The range of 0.5-1 L/min is significantly lower than the normal cardiac output for adults. Such low values could indicate severe heart failure or other critical conditions where the heart is unable to pump sufficient blood to meet the body's needs.
Choice B Reason:
A cardiac output of 10-12 L/min is higher than the normal range for adults at rest. This level of cardiac output might be seen during intense physical activity or in conditions like hyperthyroidism, where the heart pumps more blood to meet increased metabolic demands.
Choice C Reason:
The normal range for cardiac output in adults is typically between 4-6 L/min. This range represents the volume of blood the heart pumps per minute at rest, ensuring adequate perfusion of tissues and organs. Cardiac output can vary based on factors such as age, body size, and physical activity.
Choice D Reason:
A cardiac output of 15-20 L/min is extremely high and would generally be seen only during extreme physical exertion or in pathological conditions. Such high values are not typical for resting adults and indicate a state of increased cardiac demand.
Correct Answer is ["7.2"]
Explanation
Step-by-Step Calculation:
Step 1: Convert the client's weight from pounds to kilograms.
176 lbs ÷ 2.2 = 80 kg
Result = 80 kg
Step 2: Calculate the total dose of dopamine in mcg/min.
3 mcg/kg/min × 80 kg = 240 mcg/min
Result = 240 mcg/min
Step 3: Convert the total dose from mcg/min to mg/min.
240 mcg/min ÷ 1000 = 0.24 mg/min
Result = 0.24 mg/min
Step 4: Determine the concentration of dopamine in mg/mL.
500 mg ÷ 250 mL = 2 mg/mL
Result = 2 mg/mL
Step 5: Calculate the infusion rate in mL/min.
0.24 mg/min ÷ 2 mg/mL = 0.12 mL/min
Result = 0.12 mL/min
Step 6: Convert the infusion rate to mL/hr.
0.12 mL/min × 60 min/hr = 7.2 mL/hr
Result = 7.2 mL/hr
Final Result:
The IV pump should be set to 7.2 mL/hr.
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