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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 A

Explanation

A. The fifth intercostal space at the left midclavicular line is the location of the mitral valve, where murmurs associated with mitral valve disease are best auscultated.

B. The fourth intercostal space at the right sternal border is the location for assessing the tricuspid valve, not the mitral valve.

C. The third intercostal space at the left midclavicular line is not associated with loudest auscultation of the mitral valve murmur.

D. The second intercostal space at the right sternal border is where the aortic valve sounds are best heard.

A. Surgery to remove the eye B. Referral for drug rehabilitation program C. Admission for IV and intravitreal antibiotics D. Follow up with eye specialist outpatient

Correct Answer is C

Explanation

A. Surgery to remove the eye is not the immediate course of action and is only considered in severe cases where infection cannot be managed.

B. Referral for a drug rehabilitation program is beneficial for the patient's long-term health but is not the priority in this case where there is an active eye infection.

C. Admission for IV and intravitreal antibiotics is necessary to treat a possible severe eye infection, which can be sight-threatening, especially in immunocompromised patients, such as those with a history of IV drug use.

D. An outpatient follow-up with an eye specialist may be part of ongoing care but does not address the acute need for immediate antibiotic therapy to prevent further complications.

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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

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Correct Answer is A

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Correct Answer is C

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