After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?
A Anticipate intubation
B Ask client to cough, then inhale and exhale deeply
C Insert an intravenous catheter
D Administer antihypertensives
The Correct Answer is B
Choice A Rationale: Anticipating intubation is not warranted solely based on an O2 saturation of 92% and without further assessment.
Choice B Rationale: Asking the client to cough, then inhale and exhale deeply is an appropriate initial action to improve oxygenation and assess the client's respiratory status.
Choice C Rationale: Inserting an intravenous catheter is unrelated to the client's O2 saturation and would not address the immediate concern.
Choice D Rationale: Administering antihypertensives is not indicated based on the O2 saturation level, and it may not be safe without further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Rationale: Oral care is important for overall hygiene but may not take precedence over other critical aspects of care for a client with a spinal cord injury.
Choice B Rationale: Offering the client to discuss their feelings is important for emotional support but may not be the highest priority.
Choice C Rationale: Diet modifications are a high priority because they are essential for addressing the client's nutritional needs and preventing complications related to the spinal cord injury, such as pressure ulcers and infections.
Choice D Rationale: The application of compression stockings may have a role in the care plan but is not typically the highest priority for a client with a spinal cord injury.
Correct Answer is D
Explanation
Choice A Rationale: Hemiplegia involves paralysis of one side of the body and is typically associated with brain injuries or lesions, not spinal cord injuries.
Choice B Rationale: Quadriplegia involves paralysis of all four limbs and is more commonly associated with higher spinal cord injuries, not T2-T3.
Choice C Rationale: Paresthesia refers to abnormal sensations, such as tingling or numbness, and may be present in various spinal cord injuries, but it is not a type of disability.
Choice D Rationale: Paraplegia involves paralysis of the lower extremities and trunk, and it is commonly associated with spinal cord injuries at the T2-T3 level.
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