Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury?
a. Cardiac monitoring for bradycardia
b. Assessment of respiratory rate and effort
c. Application of pneumatic compression devices to legs
d. Administration of methylprednisolone (Solu-Medrol) infusion
ANS: B
Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. Methylprednisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.
You might also like to view...
A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this client's plan of care?
a. Change the dressing every 6 hours. b. Assess the wound bed once a day. c. Change the dressing when it is saturated. d. Contact the provider when the dressing leaks.
Patients with mitral stenosis may be placed on anticoagulant therapy. The nurse knows that this type of therapy may be instituted to decrease the risk of which of the following?
A) Ventricular hypertrophy B) Pulmonary embolism C) Deep vein thrombosis D) Atrial thrombus
Which of the following classifications will be used to describe a 15 year-old child with diabetes who requires daily insulin injections?
A) Type 1 diabetes B) Type 2 diabetes C) Juvenile diabetes D) Prediabetes
A client is diagnosed with mitral insufficiency, and the nurse detects a murmur with a musical quality over the apex of the heart. The nurse recognizes this is caused by:
A) regurgitation of blood from the left ventricle into the left atrium. B) enlargement of the right ventricle due to increased pressure in the right atrium. C) regurgitation of blood from the right ventricle into the right atrium. D) regurgitation of blood from the aorta into the left ventricle.