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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: While performing a daily full head-to-toe assessment is important in comprehensive patient care, this answer does not specifically address why the nurse would be particularly concerned with assessing the abdomen in a burn patient.

Choice B reason: Assessing for a paralytic ileus secondary to reduced blood flow is crucial in patients with serious burns. Burns can lead to significant physiological stress, which can decrease blood flow to the gastrointestinal tract. This reduction in blood flow can cause a paralytic ileus, a condition where the intestines do not move properly, leading to abdominal distention, pain, and decreased bowel sounds. Early detection is vital to prevent complications.

Choice C reason: While nausea and vomiting related to pain medication are possible in burn patients, the primary concern in assessing the abdomen would be to identify more serious conditions such as a paralytic ileus. This answer does not capture the immediate criticality compared to assessing for paralytic ileus.

Choice D reason: Monitoring for increased motility that may result in cramps and diarrhea is not the primary concern in burn patients. In fact, burn patients are more likely to experience decreased gastrointestinal motility due to the stress response and reduced blood flow rather than increased motility.

A. Auscultate for irregular heart tones. B. Assess for ST elevations on continuous telemetry and 12-lead EKG. C. Assess for elevated Troponin levels. D. Assess for low magnesium level. E. Assess the client's blood pressure. F. Assess if the pain radiates to the left arm.

Correct Answer is ["B","C"]

Explanation

Choice A reason: Auscultating for irregular heart tones can provide useful information about the heart’s rhythm and potential arrhythmias. However, it is not the most specific or definitive assessment for diagnosing a myocardial infarction (MI).

Choice B reason: Assessing for ST elevations on continuous telemetry and 12-lead EKG is critical in diagnosing a myocardial infarction. ST-segment elevation is a key indicator of an acute MI, specifically indicating myocardial injury. Continuous telemetry and 12-lead EKG provide real-time and detailed views of the heart's electrical activity, helping to identify ischemic changes.

Choice C reason: Assessing for elevated Troponin levels is essential because Troponins are cardiac biomarkers that increase significantly when there is damage to the heart muscle, such as during an MI. Elevated Troponin levels are highly specific and sensitive indicators of myocardial infarction, making this assessment crucial.

Choice D reason: Assessing for low magnesium levels is not directly related to diagnosing a myocardial infarction. While magnesium levels are important for overall cardiac function, they do not specifically indicate an acute MI.

Choice E reason: Assessing the client's blood pressure is an important part of a comprehensive assessment and can provide information about the patient's hemodynamic status. However, it is not specific to diagnosing a myocardial infarction.

Choice F reason: Assessing if the pain radiates to the left arm is an important symptom of a myocardial infarction. However, while it supports the suspicion of an MI, it is not as definitive as ST elevation on an EKG or elevated Troponin levels.

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The nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Assessment findings are:Temp: 99.0°FHR: 46 beats/minBP: 78/52 mmHgRR: 20 breaths/minSaO2: 94% on 2L NCWhich of the following interventions should the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

The nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. For what reason does the nurse assess the patient's abdomen?

Correct Answer is B

Explanation

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Correct Answer is ["B","C"]

Explanation

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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?