The nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?

Respirations

Pulse

Temperature

Blood Pressure

Answer and Explanation

The Correct Answer is A

A. Respirations: C4 injuries compromise the phrenic nerve, which controls the diaphragm. A high cervical spine injury can lead to respiratory failure, making airway and breathing the top priority.

B. Pulse: While monitoring circulation is important, breathing takes priority in a C4 injury due to the risk of respiratory paralysis.

C. Temperature: Temperature regulation may be affected due to autonomic dysfunction, but airway and breathing remain the priority.

D. Blood Pressure: While spinal cord injuries can cause neurogenic shock (low BP, bradycardia), ensuring airway and breathing comes first.

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Correct Answer is C

Explanation

A. "I will administer the medications 10 minutes apart."Timing is important, but this option does not specify which medication should be taken first. The correct sequence is albuterol first, followed by cromolyn.

B. "I will use both medications immediately after exercising." Cromolyn is a mast cell stabilizer used for prevention, not acute symptoms. It should be taken 15-30 minutes before exercise to prevent exercise-induced bronchospasm, not after.

C. "I will be sure to take the albuterol before taking the cromolyn." Albuterol (a bronchodilator) should be taken first to open the airways, allowing better absorption of cromolyn (an anti-inflammatory medication).

D. "If my breathing begins to feel tight, I will use the cromolyn immediately." Cromolyn is not a rescue medication. Albuterol should be used for acute bronchospasm, while cromolyn is for long-term asthma control.

A. Primary Intention B. Partial-thickness repair C. Secondary Intention D. Tertiary intention

Correct Answer is A

Explanation

A. Primary Intention: Primary intention healing occurs when surgical incisions are closed with sutures, staples, or adhesive strips. Since laparoscopic procedures involve small incisions that are closed immediately, this type of healing applies.

B. Partial-thickness repair: Partial-thickness repair refers to wounds that involve only the epidermis and part of the dermis (e.g., abrasions, minor burns). Surgical incisions are full-thickness wounds, so this is not applicable.

C. Secondary Intention: Secondary intention healing occurs when wounds heal from the inside out, typically seen in pressure ulcers, large open wounds, or infected wounds. Surgical wounds that are sutured do not heal by secondary intention.

D. Tertiary Intention: Tertiary intention healing occurs when a wound is left open initially and later closed due to infection risk or delayed healing. Laparoscopic appendectomy wounds are closed immediately, making this choice incorrect.

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The nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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