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:

Apply tight-fitting clothing

Complete frequent skin checks

Initiate a bowel regimen program

Insert an indwelling Foley catheter

Restrict all patient visitors

Answer and Explanation

Correct Answer : B,C,D

Choice A reason:

Applying tight-fitting clothing is not recommended for patients at risk of autonomic dysreflexia. Tight clothing can be a trigger for this condition by causing discomfort and potentially leading to an exaggerated autonomic response.

Choice B reason:

Completing frequent skin checks is crucial in preventing autonomic dysreflexia. Skin irritation, pressure sores, and other integumentary issues can trigger autonomic responses. Regular assessments help in early identification and prevention of potential irritants.

Choice C reason:

Initiating a bowel regimen program is essential for preventing autonomic dysreflexia. Constipation or bowel distension can be potent triggers for this condition. A consistent bowel program helps in managing and preventing these issues.

Choice D reason:

Inserting an indwelling Foley catheter is recommended to manage bladder distention, a common trigger of autonomic dysreflexia. Continuous bladder drainage prevents overdistention and reduces the risk of triggering autonomic responses.

Choice E reason:

Restricting all patient visitors is unnecessary for preventing autonomic dysreflexia. While a calm environment can be beneficial, visitor restriction is not directly related to managing the risk of this specific condition.

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Correct Answer is D

Explanation

Choice A reason:

Mechanical ventilation is not typically required for patients with rib fractures unless there is severe respiratory compromise or other underlying issues that necessitate ventilatory support.

Choice B reason:

Preparing for a chest tube is not generally required for isolated rib fractures unless there is an associated pneumothorax or hemothorax. Chest tubes are used to manage complications that involve air or blood in the pleural space.

Choice C reason:

Needle decompression is performed in emergencies to relieve tension pneumothorax. This procedure is not indicated for simple rib fractures without evidence of a tension pneumothorax.

Choice D reason:

An intercostal nerve block for pain management is an appropriate intervention for a patient with rib fractures. It helps control pain, allowing the patient to breathe deeply and cough effectively, which is important for preventing complications such as pneumonia.

A. Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain. B. Lorazepam 2 mg IV now for the client experiencing restlessness and picking at tubing. C. Morphine sulfate 4 mg IV now for the client experiencing incisional pain. D. One unit packed red blood cells STAT for the client with hemoglobin of 9.5 g/dL.

Correct Answer is A

Explanation

Choice A reason:

Administering Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain should be the nurse's priority because chest pain can be indicative of a myocardial infarction (heart attack), which is a medical emergency. Quick administration of Nitroglycerin can help to relieve chest pain, improve blood flow to the heart, and prevent further cardiac damage.

Choice B reason:

While administering Lorazepam 2 mg IV for the client experiencing restlessness and picking at tubing is important for patient safety and comfort, it is not as urgent as addressing potential cardiac issues indicated by chest pain.

Choice C reason:

Administering Morphine sulfate 4 mg IV for incisional pain management is necessary for the patient’s comfort and pain control but is not as critical as treating potential life-threatening chest pain.

Choice D reason:

Administering one unit of packed red blood cells STAT for the client with a hemoglobin of 9.5 g/dL is important but does not take precedence over the immediate risk of a myocardial infarction. The hemoglobin level, while low, is not immediately life-threatening compared to the chest pain scenario.

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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:

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