The nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Assessment findings are:
Temp: 99.0°F
HR: 46 beats/min
BP: 78/52 mmHg
RR: 20 breaths/min
SaO2: 94% on 2L NC
Which of the following interventions should the nurse anticipate?
Suction the patient immediately.
NS at 25 cc/hr.
Raise the head of the bed.
Dopamine IV drip.
HR: 46 beats/min
The Correct Answer is D
Choice A reason: Suctioning the patient immediately is not the appropriate intervention in this context. Suctioning can be necessary if the patient has secretions obstructing the airway, but it does not address the issues of bradycardia (low heart rate) and hypotension (low blood pressure) which are critical in a spinal cord injury.
Choice B reason: Administering normal saline (NS) at 25 cc/hr is not sufficient to address the patient's hypotension. In a patient with a spinal cord injury at the T5 level, hypotension is likely due to neurogenic shock, and more aggressive fluid resuscitation or pharmacological support is needed.
Choice C reason: Raising the head of the bed is not appropriate for managing the patient's condition. In fact, keeping the head elevated can worsen hypotension by reducing venous return to the heart. The focus should be on stabilizing blood pressure and heart rate.
Choice D reason: The correct intervention is starting a dopamine IV drip. Dopamine is a vasopressor that helps increase blood pressure and heart rate, which is crucial in managing neurogenic shock. By administering dopamine, the nurse can help stabilize the patient's cardiovascular status and improve perfusion to vital organs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Initiating a bowel regimen program is essential to avoid constipation, which can be a trigger for autonomic dysreflexia in patients with spinal cord injuries. Ensuring regular bowel movements helps prevent the discomfort and complications that can lead to this potentially life-threatening condition.
Choice B reason: Applying tight-fitting clothing is contraindicated as it can cause skin irritation, pressure sores, and other discomforts that could trigger autonomic dysreflexia. Loose and comfortable clothing is recommended to prevent these issues.
Choice C reason: Completing frequent skin checks is crucial for detecting and preventing pressure ulcers, skin infections, and other skin conditions that can act as noxious stimuli, triggering autonomic dysreflexia. Regular skin assessments help ensure early identification and management of potential issues.
Choice D reason: Restricting all patient visitors is not necessary for preventing autonomic dysreflexia. While it is important to manage the patient's environment and stress levels, complete visitor restriction is not a standard intervention for this condition.
Choice E reason: Inserting an indwelling Foley catheter is beneficial for managing bladder function and preventing urinary retention, a common trigger for autonomic dysreflexia. Continuous bladder drainage helps prevent distention and the subsequent risk of triggering this condition.
Correct Answer is B
Explanation
Choice A reason: An increased heart rate is not an expected therapeutic response to adenosine. Adenosine is used to slow the heart rate by temporarily blocking the electrical conduction through the atrioventricular (AV) node. This action is crucial in managing supraventricular tachycardia (SVT), as it can help restore a normal heart rhythm. An increased heart rate would suggest that the medication is not working as intended, and the underlying tachycardia may persist or worsen.
Choice B reason: A short period of asystole is the correct and expected therapeutic response when administering adenosine. Adenosine works by briefly stopping the heart's electrical activity, leading to a brief asystole (lack of heartbeat). This allows the heart's natural pacemaker to reset and potentially restore a normal rhythm. Although this can be alarming, it is a known and anticipated effect of the drug, and it typically resolves quickly as the heart resumes normal activity.
Choice C reason: Hypertension is not an expected response to adenosine. Adenosine generally causes vasodilation, which can lower blood pressure. The primary focus of adenosine in the context of SVT is on its cardiac effects rather than influencing blood pressure significantly. If hypertension occurs, it may be unrelated to the administration of adenosine and could indicate another underlying issue that needs to be addressed.
Choice D reason: Decreased intraocular pressure is not a relevant or expected response to adenosine administration in the context of managing SVT. Adenosine's primary effect is on the heart's electrical conduction system, and it does not significantly impact intraocular pressure. The focus should remain on observing the cardiac responses to ensure the medication is effectively managing the SVT.
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