The arterial blood gas (ABG) report of a patient with a spinal cord injury indicates hypoxia. Select two interventions the nurse would perform to improve the patient's respiratory status.

Perform assisted coughing.

Administer steroids.

Administer oxygen.

Administer antibiotic drugs.

Answer and Explanation

Correct Answer : A,C

Choice A reason: Performing assisted coughing is crucial for patients with spinal cord injuries who may have weakened respiratory muscles. Assisted coughing helps clear secretions from the airways, thus improving oxygenation and preventing respiratory complications like pneumonia.

Choice B reason: Administering steroids is not a primary intervention for addressing hypoxia in patients with spinal cord injuries. Steroids can be used to reduce inflammation, but they do not directly improve respiratory status or oxygenation.

Choice C reason: Administering oxygen is a direct and effective intervention for managing hypoxia. Supplemental oxygen helps ensure that the patient maintains adequate blood oxygen levels, which is critical for overall tissue perfusion and function.

Choice D reason: Administering antibiotics is not immediately relevant to the treatment of hypoxia unless there is an underlying infection causing or contributing to respiratory distress. Antibiotics are used to treat infections, not directly to improve respiratory status in cases of hypoxia.

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Correct Answer is B

Explanation

Choice A reason: Urine output of 30 mL/hr is concerning as it is on the lower end of normal and can indicate dehydration or impaired renal function. However, in this context, it is less immediately alarming compared to severely low blood pressure.

Choice B reason: Blood pressure of 90/40 is critically low and indicates hypotension, which can be a sign of severe dehydration or shock, especially in a patient with ongoing nausea and vomiting. This requires immediate attention and intervention to stabilize the patient and prevent further complications.

Choice C reason: An infiltrated IV site is a problem that needs to be addressed to ensure proper administration of fluids and medications. However, it is not as immediately life-threatening as hypotension.

Choice D reason: Oral fluid intake of 100 mL for 8 hours is inadequate, suggesting that the patient may be dehydrated. While concerning, it is not as acutely critical as low blood pressure, which directly affects perfusion and organ function.

A. Check the blood pressure B. Obtain a bladder scan C. Notify the doctor D. Elevate the head of the bed to 45 degrees

Correct Answer is D,A,B,C

Explanation

Choice D reason: Elevating the head of the bed to 45 degrees is the first intervention the nurse should perform. This position helps lower the patient's blood pressure by promoting venous pooling in the lower extremities and reducing the return of blood to the heart. It also aids in better breathing and overall comfort.

Choice A reason: Checking the blood pressure is crucial in this situation to confirm if the patient is experiencing autonomic dysreflexia, which is characterized by a sudden and severe increase in blood pressure. This step helps in assessing the severity of the condition and guiding subsequent interventions.

Choice B reason: Obtaining a bladder scan is important because a full bladder is a common trigger of autonomic dysreflexia. By identifying and addressing the cause of the distension, the nurse can help alleviate the symptoms and prevent further complications.

Choice C reason: Notifying the doctor is a critical step, as autonomic dysreflexia is a medical emergency that requires prompt medical intervention. The healthcare provider can give additional orders and may administer medication to control the patient's blood pressure and relieve symptoms.

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The arterial blood gas (ABG) report of a patient with a spinal cord injury indicates hypoxia. Select two interventions the nurse would perform to improve the patient's respiratory status.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

Correct Answer is B

Explanation

Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.

Correct Answer is D,A,B,C

Explanation

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