The nurse is assessing a patient with suspected traumatic cervical spine injury who just arrived to the emergency department. The nurse knows the priority actions for caring for this patient include all of the following. Place the actions in order of priority.

Complete a Glasgow Coma Scale assessment.

Apply pressure to any areas of uncontrolled bleeding.

Place an indwelling Foley catheter to monitor urine output.

Answer and Explanation

The Correct Answer is B,A,C

Choice A reason:

Completing a Glasgow Coma Scale assessment is crucial in evaluating the neurological status of a patient with a suspected traumatic cervical spine injury. However, it should be done after ensuring that there is no uncontrolled bleeding.

Choice B reason:

Applying pressure to any areas of uncontrolled bleeding is the highest priority. Controlling bleeding is essential to prevent hypovolemic shock and maintain hemodynamic stability, which takes precedence over other assessments and interventions.

Choice C reason:

Placing an indwelling Foley catheter to monitor urine output is important for ongoing assessment of renal function and fluid balance. However, it is not the immediate priority compared to controlling bleeding and assessing neurological status.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:

While preparing the gastrointestinal tract for enteral feedings is important, it is not the primary reason for administering famotidine. Famotidine is typically used to reduce gastric acid production, not to prepare the GI tract for feedings.

Choice B reason:

Increasing the motility of the gastrointestinal tract is not the primary function of famotidine. Famotidine is an H2 receptor antagonist that works by decreasing the production of stomach acid.

Choice C reason:

Keeping the gastrointestinal tract functioning normally is a broad statement and does not specifically address the reason for administering famotidine. The drug's role in preventing stress ulcers is more relevant to the patient's current condition.

Choice D reason:

Famotidine is used to prevent stress ulcers, which can occur in critically ill patients, including those on mechanical ventilation. The stress of illness and mechanical ventilation increases the risk of developing gastric ulcers, and famotidine helps reduce this risk by decreasing gastric acid secretion.

A. Specific gravity. B. Level of consciousness. C. Urine output. D. Blood pressure.

Correct Answer is C

Explanation

Choice A reason:

A decrease in specific gravity is not the primary therapeutic outcome of desmopressin in the treatment of diabetes insipidus. Desmopressin works by increasing water reabsorption in the kidneys, which leads to a decrease in urine output and an increase in urine concentration, reflected by an increase, not a decrease, in specific gravity.

Choice B reason:

A decrease in the level of consciousness is not an intended therapeutic outcome and would be concerning if observed. Desmopressin aims to control symptoms of diabetes insipidus, not alter the patient’s mental status.

Choice C reason:

A decrease in urine output is the primary therapeutic outcome of desmopressin in a patient with diabetes insipidus. Desmopressin mimics the action of antidiuretic hormone (ADH), leading to increased water reabsorption in the kidneys and reduced urine volume.

Choice D reason:

Desmopressin does not primarily aim to decrease blood pressure. Its main effect is on water reabsorption in the kidneys, thereby reducing urine output. While it can have some impact on blood pressure, this is not its primary therapeutic outcome.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is assessing a patient with suspected traumatic cervical spine injury who just arrived to the emergency department. The nurse knows the priority actions for caring for this patient include all of the following. Place the actions in order of priority.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is on mechanical ventilation and the client's spouse wonders why famotidine is needed since the client "only has lung problems." What response by the nurse is best?

Correct Answer is D

Explanation

A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving desmopressin. The nurse understands the therapeutic outcome is a decrease in:

Correct Answer is C

Explanation

A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

Which would be the most important action immediately following extubation of a patient?

A nurse assesses a patient with a spinal cord injury at level T5. The patient's blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first in response to this complication?

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries: