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: Quadriplegia is a type of paralysis that affects all four limbs and the trunk, usually caused by an injury to the cervical spine (C1-C8).
Choice B Rationale: Incomplete loss of function refers to the extent of injury and whether some neurological function remains, not the level of injury.
Choice C Rationale: CA injury refers to cervical spine injury, which is the most common level of spinal cord injury.
Choice D Rationale: Hyperextension, like other mechanisms of injury (such as compression, flexion, or flexion-rotation), can contribute to spinal cord injury but does not define the level of injury.
Correct Answer is D
Explanation
Choice A Rationale: Leakage is not typically associated with upper motor neuron deficits related to a spinal cord injury.
Choice B Rationale: Anuria (absence of urine production) is not a common manifestation of upper motor neuron deficits in this context.
Choice C Rationale: A flaccid bladder and an inability to voluntarily void are more characteristic of lower motor neuron deficits. Upper motor neuron deficits often lead to spasticity and involuntary voiding.
Choice D Rationale: Spasticity and involuntary voiding are common manifestations of upper motor neuron deficits related to spinal cord injury. This is due to the loss of inhibitory control over reflexes, including the micturition reflex.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today