Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

The spouse assists the client into a wheelchair and coaches deep coughing.

The spouse assists the client into high-Fowler position and encourages taking a number of deep breaths.

The spouse places hands on the client's lateral chest and pushes inward on exhalation.

The spouse places hands below the client's diaphragm and pushes upward with exhalation.

Answer and Explanation

The Correct Answer is D

Choice A reason:

While assisting the client into a wheelchair and coaching deep coughing can be beneficial, it does not specifically describe the technique for performing assistive coughing, which is crucial for a quadriplegic patient who cannot generate effective coughs on their own.

Choice B reason:

Placing the client in a high-Fowler position and encouraging deep breaths can be helpful in enhancing lung expansion and breathing, but it does not address the specific method of assistive coughing, which requires manual assistance to be effective.

Choice C reason:

Placing hands on the lateral chest and pushing inward on exhalation is not the correct technique for assistive coughing. This method may not generate sufficient force to help with airway clearance in a quadriplegic patient.

Choice D reason:

Placing hands below the client's diaphragm and pushing upward with exhalation is the correct technique for assistive coughing, also known as quad coughing. This method helps to increase the force of the cough, allowing for better clearance of secretions from the airway, which is essential for patients with quadriplegia.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

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.

A. Elevate the client's head on two pillows B. Decrease the noise level in the client's room C. Suction the endotracheal tube frequently D. Administer a stool softener E. Give a 500cc NS fluid bolus

Correct Answer is ["B","D","E"]

Explanation

Choice A reason:

Elevating the client's head on two pillows is not a standardized method for managing intracranial pressure. Instead, elevating the head of the bed to 30 degrees is a more effective strategy to promote venous drainage and reduce ICP.

Choice B reason:

Decreasing the noise level in the client's room helps create a calm environment, which can reduce stress and prevent increases in ICP. Excessive noise and stimulation can elevate intracranial pressure.

Choice C reason:

Frequent suctioning of the endotracheal tube can actually increase ICP due to the stimulation and potential for causing a cough reflex. Suctioning should be performed only as necessary and with care.

Choice D reason:

Administering a stool softener helps prevent straining during bowel movements, which can increase ICP. Ensuring regular and comfortable bowel movements is crucial in managing intracranial pressure.

Choice E reason:

Giving a 500cc NS fluid bolus can be appropriate in some clinical scenarios to maintain adequate blood pressure and perfusion. However, fluid management must be carefully balanced to avoid fluid overload, which could increase ICP. Generally, fluid boluses are not the primary method for managing ICP.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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:

Correct Answer is B

Explanation

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

To evaluate the effectiveness of mannitol, the nurse should monitor:

A patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority?

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

After a craniotomy, the nurse assesses the patient and finds generalized edema, decreased urine output, acute confusion, and muscle weakness. The client has IV fluids running at 75 mL/hr. What action should the nurse take first?

A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

You are caring for a patient in the ED who came in after a hard tackle in a football game. The x-rays show that he has a fracture of 2 ribs on the right side. Which intervention will the nurse expect for this patient?

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

The nurse is caring for a patient who is on mechanical ventilation and the high pressure alarm is sounding. Which of the following is the most likely cause?