The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

Temperature of 96.8°F

Blood pressure 110/68

Respiratory rate of 20 breaths/min

Heart rate of 70 beats/min

Answer and Explanation

The Correct Answer is B

Choice A reason:

A temperature of 96.8°F is within the normal range for a human body (97.8°F to 99.1°F). However, it does not necessarily indicate the desired effect of Dopamine. Dopamine is primarily used to improve blood flow and cardiac output, particularly in critically ill patients. Therefore, temperature alone is not a reliable indicator of its effectiveness.

Choice B reason:

Blood pressure of 110/68 mmHg suggests that the Dopamine is effectively maintaining the patient's hemodynamic stability. Dopamine is often used to support blood pressure in patients with hypotension, particularly after spinal cord injuries. Maintaining an adequate blood pressure ensures that vital organs receive sufficient blood flow, which is a key therapeutic goal of Dopamine administration.

Choice C reason:

A respiratory rate of 20 breaths/min is considered normal for an adult (12-20 breaths/min). While normal respiratory rate is a positive sign, it is not a direct measure of Dopamine's effectiveness. Dopamine's primary action is on the cardiovascular system, so a normal respiratory rate alone does not necessarily indicate that the drug is having the desired effect.

Choice D reason:

A heart rate of 70 beats/min is within the normal range for adults (60-100 beats/min). Similar to the respiratory rate, while a normal heart rate is beneficial, it is not a direct indicator of Dopamine's effectiveness. Dopamine's role in improving cardiac output and blood pressure is more critical in assessing its desired effects.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:

Autonomic dysreflexia is a serious condition that can occur in individuals with spinal cord injuries, particularly those at or above the T6 level. It is a secondary injury mechanism that results from the autonomic nervous system's abnormal response to stimuli below the level of injury, leading to severe hypertension and other complications.

Choice B reason:

Ischemia, or reduced blood flow, is a common cause of secondary injury following a spinal cord injury. It can result from initial trauma or subsequent swelling and vascular damage, leading to further cell death and tissue damage.

Choice C reason:

Edema, or swelling, is another cause of secondary injury in spinal cord injuries. The inflammatory response to injury can cause fluid accumulation, increasing pressure within the spinal column and exacerbating damage to spinal cord tissues.

Choice D reason:

Axial loading is a primary mechanism of spinal cord injury, not a secondary injury cause. It refers to the vertical force applied along the axis of the spine, typically resulting from falls or direct blows, leading to compression and potential fractures.

Choice E reason:

Hemorrhage, or bleeding, is a significant cause of secondary injury in spinal cord trauma. It can result from blood vessel damage at the injury site, leading to increased pressure, further tissue damage, and impaired blood flow.

A. Administer Atropine. B. Call the health care provider immediately. C. Continue to clear the airway. D. Stop suctioning the patient.

Correct Answer is D

Explanation

Choice A reason:

Administering Atropine can increase the heart rate, but it is not the immediate first action. The priority is to stop the stimulus causing the vagal response, which in this case is the suctioning.

Choice B reason:

Calling the healthcare provider is important, but the immediate action should be to stop the suctioning to eliminate the cause of the vagal response. Once the immediate issue is addressed, notifying the provider can follow.

Choice C reason:

Continuing to clear the airway can exacerbate the vagal response and worsen the patient's condition. The immediate action should be to stop the suctioning.

Choice D reason:

Stopping the suctioning is the best immediate action to take when the patient becomes diaphoretic, nauseous, and experiences a significant drop in heart rate. This response is likely due to vagal stimulation, and stopping the suctioning will help alleviate the symptoms.

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The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

Correct Answer is ["A","B","C","E"]

Explanation

During routine suctioning of a client with an endotracheal tube, the patient becomes diaphoretic and nauseous, and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?

Correct Answer is D

Explanation

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