The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)

Blood pressure

Bladder function

Heart rate

Reflexes

Respirations

Answer and Explanation

Correct Answer : A,C,E

A. Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations.

B. Bladder function is impacted by spinal cord injuries; however, it is not the initial priority in an emergency setting when life-threatening complications must be managed first.

C. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia.

D. Reflexes are often assessed in cases of spinal injury, but they are not the immediate priority when stabilizing the patient upon arrival.

E. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.

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Correct Answer is ["1.3"]

Explanation

To calculate the dosage of clindamycin, first convert the patient's weight from pounds to kilograms, knowing that 1 kg equals 2.2 lbs. The patient weighs 88 lbs, which is equivalent to 40 kg (88 lbs / 2.2 lbs per kg). The prescribed dose is 10 mg/kg/day, so the patient requires 400 mg/day (10 mg/kg * 40 kg). Since the medication is to be administered in two divided doses, each dose will be half of the daily requirement, resulting in 200 mg per dose. The medication is supplied at a concentration of 150 mg/mL, so to find out how many milliliters per dose, divide the dose in milligrams by the concentration: 200 mg / 150 mg/mL, which equals 1.33 mL. Rounded to the nearest tenth, the nurse will administer 1.3 mL per dose.

A. Bradycardia B. Sepsis C. Hypertension D. Respiratory compromise

Correct Answer is D

Explanation

A. Bradycardia is possible due to autonomic dysfunction but is not the leading cause of death.

B. Sepsis can occur due to immobility and pressure injuries but is secondary to respiratory compromise.

C. Hypertension is not directly linked to high cervical spine injuries and is less common than respiratory issues in this setting.

D. Respiratory compromise is the primary cause of complications or death in patients with a high cervical spine injury (C-3 and above) due to loss of innervation to the diaphragm and intercostal muscles, which impairs spontaneous breathing. Mechanical ventilation is often required to maintain adequate oxygenation.

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The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

A physician prescribes clindamycin 10 mg/kg/day IV in two divided doses for respiratory tract infection. The medication is supplied 150 mg/mL. The patient weighs 88 lbs. How much will the nurse administer per dose? (round to the nearest tenth)

Correct Answer is ["1.3"]

Explanation

The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this injury?

Correct Answer is D

Explanation

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