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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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Free Nursing Study Resources

Correct Answer is ["0.5"]

Explanation

To administer the correct dose of Morphine, the nurse needs to calculate the volume of medication to deliver 1 mg of Morphine. Since the medication is supplied in a concentration of 2 mg per 1 mL, the nurse would administer half of the volume of the vial to provide the ordered 1 mg dose. Therefore, the nurse should administer 0.5 mL of Morphine to the patient.

A. Elevate the head of the bed, loosen clothing, and check the urinary catheter for obstruction B. Elevate the head of the bed and apply a cool compress to the forehead C. Place in Semi-Fowler's position and establish IV access D. Establish IV access, apply 2 liters of nasal oxygen, and contact the health care provider

Correct Answer is A

Explanation

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

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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

A patient is ordered 1 mg of Morphine IV push. The medication is supplied in vials 2 mg/1 mL. What should the nurse administer? (round to the nearest tenth)

Correct Answer is ["0.5"]

Explanation

The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Correct Answer is A

Explanation

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