In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].)
a. Infuse normal saline at 150 mL/hr.
b. Monitor cardiac rhythm and blood pressure.
c. Administer O2 using a non-rebreather mask.
d. Immobilize the patient's head, neck, and spine.
e. Transfer the patient to radiology for spinal computed tomography (CT).
ANS:
D, C, B, A, E
The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.
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