The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?

Frequent passive range of motion

Coughing and deep breathing exercises once per shift

Turn patient every 4 hours

Ambulate patient twice per shift

Answer and Explanation

The Correct Answer is A

A. Frequent passive range of motion exercises are crucial for preventing complications of immobility, such as contractures and pressure ulcers, and to promote circulation in patients with spinal cord injuries.

B. While coughing and deep breathing exercises are important for respiratory health, they should be performed more frequently than once per shift in patients with reduced mobility to prevent respiratory complications.

C. Turning the patient every 4 hours may not be adequate to prevent pressure ulcers; typically, patients should be turned at least every 2 hours.

D. Patients with a complete spinal cord injury at C7 typically lack the ability to ambulate, making this intervention inappropriate.

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Correct Answer is A

Explanation

A. Neurogenic shock occurs in spinal cord injuries above T6 and is characterized by hypotension, bradycardia, and loss of sympathetic tone below the level of injury. This condition results from disruption of autonomic pathways.

B. Brain herniation typically involves increased intracranial pressure and different neurological symptoms.

C. Spinal shock involves temporary loss of reflexes and sensation but does not specifically cause bradycardia or hypotension.

D. Autonomic dysreflexia involves sudden high blood pressure and is usually triggered by noxious stimuli, occurring after the acute phase of SCI.

Correct Answer is ["16"]

Explanation

To calculate the dosage of Vancomycin, first convert the patient's weight from pounds to kilograms, knowing that 1 kg equals 2.2 lbs. The patient weighs 110 lbs, which is equivalent to 50 kg (110 lbs / 2.2). Next, multiply the patient's weight in kilograms by the prescribed dosage of 20 mg/kg, resulting in a total dosage of 1000 mg (50 kg * 20 mg/kg). Since the vials contain 500 mg per 8 mL, divide the total dosage required by the amount per vial to find out how many milliliters should be withdrawn. This results in 16 mL (1000 mg / (500 mg/8 mL)).

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The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient immediately after a spinal cord injury between T7-T8 vertebrae. The patient displays the following symptoms: absent reflexes, flaccidity, loss of sensation below the level of injury, bradycardia, and hypotension. These are signs of which condition?

Correct Answer is A

Explanation

A physician prescribes Vancomycin 20 mg/kg intravenous (IV). The patient weighs 110 lbs. The medication is available in vials which contain 500 mg per 8 mL. What should the nurse withdraw from the vial? (round to the nearest whole number)

Correct Answer is ["16"]

Explanation

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