After performing an assessment on a client with a spinal cord injury, which intervention will the nurse employ to prevent cardiovascular complications?

A Sit the client at a 90 degree angle

B Administer 2000 liters of fluid

C Apply compression socks

D Maintain blood pressure exactly at 110/80

Answer and Explanation

The Correct Answer is A

Choice A Rationale: Sitting the client at a 90-degree angle (upright position) helps prevent orthostatic hypotension and cardiovascular complications in clients with spinal cord injuries by improving venous return and cardiac output.

Choice B Rationale: Administering 2000 liters of fluid is an inappropriate intervention, and the volume mentioned is excessive.

Choice C Rationale: Applying compression socks may help prevent deep vein thrombosis (DVT) but does not address cardiovascular complications related to sitting position.

Choice D Rationale: Maintaining blood pressure exactly at 110/80 is not a feasible or appropriate intervention.

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Correct Answer is C

Explanation

Choice A Rationale: Notifying the nurse administrator should not be the first action when a client is experiencing pain or injury.

Choice B Rationale: Cleaning up the spill is important to prevent further accidents but does not address the client's immediate pain and discomfort.

Choice C Rationale: Asking the client to remain still is the best first action to ensure the client's safety and assess the extent of the injury or pain.

Choice D Rationale: Documenting the incident is important but should follow

A. A measure the calves for symmetry B. B palpate the bladder C. C Place a pillow between the knees and ankles D. D Check the gag reflex

Correct Answer is C

Explanation

Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.

Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.

Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.

Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.

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After performing an assessment on a client with a spinal cord injury, which intervention will the nurse employ to prevent cardiovascular complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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