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.
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 D
Explanation
Choice A reason: A nursing assistant is not typically qualified to verify and administer blood products. Their role primarily involves providing basic patient care under the supervision of licensed nurses.
Choice B reason: A physician's assistant (PA) is a licensed medical professional who can perform many tasks, but verifying and administering blood products is generally within the nursing scope of practice. The PA may assist but is not the primary person for this task.
Choice C reason: The unit secretary handles administrative tasks and coordination but is not involved in clinical tasks such as verifying and administering blood products.
Choice D reason: Another registered nurse (RN) is the appropriate team member to assist in checking a unit of packed red blood cells before administration. RNs are trained and qualified to perform this task, ensuring that the right blood type and unit are administered to the patient safely.
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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