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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To administer the correct dose of Morphine, the nurse needs to calculate the volume of medication to deliver 1 mg of Morphine. Since the medication is supplied in a concentration of 2 mg per 1 mL, the nurse would administer half of the volume of the vial to provide the ordered 1 mg dose. Therefore, the nurse should administer 0.5 mL of Morphine to the patient.
Correct Answer is B
Explanation
A. While taking some medications with food or milk can help with absorption, this is not a specific requirement for lisinopril.
B. Lisinopril, an ACE inhibitor, can lead to elevated potassium levels. Periodic monitoring of potassium levels is essential to prevent hyperkalemia, a potentially dangerous side effect.
C. Increasing intake of green vegetables is generally healthy but does not directly impact lisinopril's effects.
D. Many salt substitutes contain potassium, which could elevate potassium levels further when taken with ACE inhibitors like lisinopril, posing a risk for hyperkalemia.
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