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The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

Padded tongue blades to prevent injury in the event of seizure

Soft wrist restraints to prevent injury

Ambu bag and oxygen connection for respiratory distress

Wrenches for emergency removal of traction equipment

Oral suction tube (Yankaur) for secretion removal

Answer and Explanation

Correct Answer : C,D,E

A. Padded tongue blades are not appropriate for seizure management and are not necessary in this context.

B. Soft wrist restraints are not required in this scenario unless otherwise indicated.

C. An Ambu bag and oxygen are crucial for respiratory support, especially if the patient has compromised breathing due to spinal cord injury.

D. Wrenches should be readily available to quickly remove halo traction in case of an emergency, such as if the patient's airway needs to be accessed.

E. An oral suction tube (Yankauer) is important for managing oral secretions, which can be challenging for patients with limited mobility.

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Correct Answer is C

Explanation

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

A. Bradycardia and hypotension B. Tachycardia and dry cough C. Scleral injection and tearing D. Changes in eye pigmentation

Correct Answer is A

Explanation

A. Timolol is a beta-blocker that can be absorbed systemically, leading to side effects such as bradycardia and hypotension, which require monitoring.

B. Tachycardia and dry cough are not common side effects of timolol; dry cough is more associated with ACE inhibitors.

C. Scleral injection and tearing are not common side effects and are not expected with timolol use.

D. Changes in eye pigmentation are more commonly seen with prostaglandin analogs, not with beta-blockers like timolol.

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The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Correct Answer is C

Explanation

The provider has prescribed timolol ophthalmic drops for the patient diagnosed with glaucoma. The nurse should assess the patient for which of the following side effects?

Correct Answer is A

Explanation

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