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. Apply a vest restraint on the client. B. Place the client in bed with the two side rails raised. C. Place a seat alarm in the client's chair. D. Administer lorazepam the client.

Correct Answer is C

Explanation

Choice A Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.

Choice B Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.

Choice C Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.

Choice D Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted

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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?

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Naxlex Comprehensive Predictor Exams

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