A patient with spinal cord injury has altered-mobility, which increases the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent DVT formation?

Applying a sequential compression device

Administering an antifibrinolytic agent

Placing the patient on a fluid restriction

Assisting the patient with passive ROM exercises

Answer and Explanation

The Correct Answer is A

A. Applying a sequential compression device. – Correct Answer. SCDs help prevent venous stasis, reducing the risk of DVT in immobile patients.

B. Administering an antifibrinolytic agent. – Incorrect. Antifibrinolytics promote clot formation and are used for bleeding disorders, not DVT prevention.

C. Placing the patient on a fluid restriction. – Incorrect. Adequate hydration is important to prevent blood viscosity and clot formation.

D. Assisting the patient with passive ROM exercises. – Incorrect. Passive ROM helps circulation, but SCDs provide more effective DVT prevention.

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Correct Answer is C

Explanation

A. Suggest the visitors stay a bit longer to provide support and distraction. – Noise and stimulation can worsen migraines.

B. Suggest the patient ambulates in the hallway to become fatigued, so they can rest. – Movement may increase pain.

C. Turn the lights and television off except for a night light. – Correct Answer. Migraines are worsened by light and noise, so a dark and quiet environment is best.

D. Turn on the television to be used as a distractor for the patient. – Bright lights and sound can aggravate symptoms.

A. Dextrose 5% in 0,45% sodium chloride IV B. Oral hypoglycemic medications C. Glucocorticoid medications D. 0.9% sodium chloride IV

Correct Answer is D

Explanation

A. Dextrose 5% in 0.45% sodium chloride IV. – Incorrect. Dextrose is given later, after blood glucose drops below 250 mg/dL to prevent hypoglycemia.

B. Oral hypoglycemic medications. – Incorrect. DKA requires IV insulin, not oral medications.

C. Glucocorticoid medications. – Incorrect. Glucocorticoids can worsen hyperglycemia by increasing blood sugar.

D. 0.9% sodium chloride IV. – Correct Answer. Fluid resuscitation with normal saline is the first priority to correct hypovolemia caused by osmotic diuresis in DKA.

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A patient with spinal cord injury has altered-mobility, which increases the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent DVT formation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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