Question

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:

Answer 1

Correct Answers:

Blood pressure 110/68

Rationale :

✅ Dopamine is used in spinal cord injury to maintain adequate tissue perfusion by increasing mean arterial pressure (MAP) through beta-1 adrenergic stimulation, which boosts cardiac output.

✅ A BP of 110/68 mm Hg indicates effective perfusion restoration, preventing secondary spinal cord ischemia.

✅ Target MAP is typically 85–90 mm Hg for optimal spinal cord perfusion.

✅ Other parameters (temperature, respiratory rate, HR) may vary but are not primary indicators of dopamine effectiveness.

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Answer 2

Correct Answers:

Elevate the head of the bed immediately and notify the provider

Rationale :

🟢 Autonomic dysreflexia is a life-threatening emergency associated with spinal cord lesions at or above T6.

🟢The sudden hypertension (BP 190/100), headache, and flushed skin are hallmark signs. Rapid action is crucial to prevent stroke or seizures.

🟢 Elevating the head of the bed to 45–90 degrees is the first intervention because it promotes orthostatic pooling of blood in the lower extremities, effectively reducing blood pressure and decreasing the risk of intracranial hemorrhage.

🟢 Sitting the patient upright decreases sympathetic stimulation by reducing venous return, which helps counteract the excessive vasoconstriction caused by dysreflexia.

🟢 The nurse should loosen restrictive clothing and search for triggering stimuli such as bladder distention, bowel impaction, or skin irritation after elevating the bed.

🟢Treating the cause is essential for definitive management.

🟢 Immediate notification of the provider is required because uncontrolled hypertension can rapidly progress to hypertensive crisis, and additional pharmacologic interventions (e.g., antihypertensives) may be necessary.

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Answer 3

Correct Answers:

Monitor respiratory effort and oxygen saturation level

Rationale :

🟡 High cervical spinal cord injuries (C3–C4) involve the phrenic nerve, which controls the diaphragm, making the client highly susceptible to respiratory compromise.

🟡Airway and breathing are always the first priority (ABCs) in emergency care.

🟡 Monitoring respiratory effort helps detect early signs of hypoventilation, diaphragmatic fatigue, or respiratory arrest, which are common complications in injuries above C5.

🟡 Oxygen saturation monitoring provides a continuous assessment of gas exchange and allows for early intervention with oxygen supplementation or mechanical ventilation if needed.

🟡 Early detection of respiratory insufficiency prevents hypoxia, which can lead to irreversible brain injury or cardiac arrest if unrecognized.

🟡 Ensuring airway patency and adequate ventilation takes precedence over neurologic assessment or circulatory monitoring because respiratory failure is the most immediate life-threatening concern in high spinal injuries.

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Answer 4

Correct Answers:

Hypotension, bradycardia, and warm extremities

Rationale :

🟢 Spinal shock is characterized by a temporary loss of all neurologic activity below the level of injury, including motor, sensory, and reflex functions.

🟢Flaccid paralysis and absent sensation are classic early signs.

🟢 The condition occurs immediately after a spinal cord injury due to transient suppression of spinal reflexes, resulting in areflexia and loss of muscle tone.

🟢 The duration of spinal shock varies but typically resolves once reflexes gradually return, signaling the transition to other phases of spinal cord injury recovery.

🟢 Identifying flaccid paralysis and sensory loss early helps differentiate spinal shock from other conditions such as neurogenic shock (which involves autonomic dysfunction) or autonomic dysreflexia (which occurs later in recovery).

🟢 Prompt recognition allows the nurse to implement supportive care, including immobilization, blood pressure support, and close neurologic monitoring, to prevent further complications.

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Answer 5

Correct Answers:

Vitamin K

Rationale :

🟢 Vitamin K is the antidote for warfarin toxicity, reversing its anticoagulant effects by promoting the synthesis of clotting factors II, VII, IX, and X in the liver.

🟢 Administering vitamin K corrects prolonged prothrombin time (PT) and international normalized ratio (INR), reducing the risk of severe bleeding.

🟢 Rectal bleeding in a patient on warfarin indicates excessive anticoagulation, requiring immediate reversal to prevent hemorrhagic complications.

🟢 Parenteral administration (IV or subcutaneous) is preferred in severe bleeding, while oral routes are used in less critical cases.

🟢 Monitoring coagulation levels after administration ensures effective reversal and guides further dosing.

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Answer 6

Correct Answers:

Limit fluid intake to 2 liters/day.

Rationale :

🟢 Heart failure patients often experience fluid overload, which can worsen pulmonary congestion and edema.

🟢 Limiting fluid intake to 2 liters/day helps prevent volume overload and reduces the strain on the compromised heart.

🟢 Fluid restriction, along with sodium control, is a standard non-pharmacologic management strategy for heart failure.

🟢 Accurate daily weights and intake/output monitoring help assess fluid status and detect early signs of fluid retention.

🟢 Patient education on fluid management is crucial to prevent decompensation and repeated hospital admissions.

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Answer 7

Correct Answers:

The patient is coughing

Rationale :

🟢 High-pressure alarms on mechanical ventilators are triggered when there is increased resistance in the airway or tubing.

🟢 Coughing causes temporary bronchospasm or secretion movement, leading to increased airway pressure.

🟢 Other common causes include kinks in the tubing or secretions, but coughing is the most common and benign cause.

🟢 The nurse should first assess the patient’s condition before adjusting the ventilator, as patient safety is the priority.

🟢 If coughing persists, suctioning may be required to clear secretions and relieve the obstruction.

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Answer 8

Correct Answers:

83

Rationale :

✍️ Formula:

Rate (mL/hr) = Total volume (mL) ÷ Time (hr).

✍️ Calculation:

330 mL ÷ 4 hr

82.5 mL/hr.

✍️ Rounding: Always round to the nearest whole number for infusion pumps

83 mL/hr.

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Answer 9

Correct Answers:

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

Rationale :

🟢 Quad coughing assists patients with quadriplegia, who lack abdominal muscle control, to generate an effective cough.

🟢 The upward thrust below the diaphragm during exhalation increases intrathoracic pressure, helping to expel secretions.

🟢 Proper technique prevents atelectasis and pneumonia, common complications in immobile patients.

🟢 Family caregiver training improves independent airway clearance at home.

🟢 This technique is performed in synchronization with the patient’s breathing to maximize effectiveness.

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Answer 10

Correct Answers:

Maintaining adequate organ perfusion

Rationale :

🟢 The priority in organ donor care after brain death is to maintain viable organs for transplantation.

🟢 Adequate organ perfusion ensures optimal oxygenation and nutrient delivery to the organs.

🟢 This involves hemodynamic stability, including appropriate fluid administration and vasopressor use if necessary.

🟢 Preventing hypotension and hypoxia is essential to avoid organ ischemia.

🟢 Other measures include temperature regulation and infection prevention, but perfusion is the top priority.

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Adult Health-Viterbo University

No.

1 :
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:

2 :
A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

3 :
A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

4 :
A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

5 :
A nurse in the ED is assessing a client who is taking warfarin and experiencing rectal bleeding. Which of the following drugs should the nurse anticipate administering to the client?

6 :
A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

7 :
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?

8 :
A nurse is preparing to infuse one unit, 330 mL, of packed red blood cells over 4 hours to a patient with heart failure. The nurse should set the pump to deliver how many mL/hr?Round to the nearest whole number.

9 :
Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

10 :
After brain death has been determined, which of the following is a priority nursing action in caring for an organ donor?

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Adult Health-Viterbo University

No.

1 : 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:

2 : A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

3 : A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

4 : A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

5 : A nurse in the ED is assessing a client who is taking warfarin and experiencing rectal bleeding. Which of the following drugs should the nurse anticipate administering to the client?

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

7 : 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?

8 : A nurse is preparing to infuse one unit, 330 mL, of packed red blood cells over 4 hours to a patient with heart failure. The nurse should set the pump to deliver how many mL/hr?Round to the nearest whole number.

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

10 : After brain death has been determined, which of the following is a priority nursing action in caring for an organ donor?

1 :
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:

2 :
A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

3 :
A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

4 :
A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

5 :
A nurse in the ED is assessing a client who is taking warfarin and experiencing rectal bleeding. Which of the following drugs should the nurse anticipate administering to the client?

6 :
A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

7 :
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?

8 :
A nurse is preparing to infuse one unit, 330 mL, of packed red blood cells over 4 hours to a patient with heart failure. The nurse should set the pump to deliver how many mL/hr?Round to the nearest whole number.

9 :
Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

10 :
After brain death has been determined, which of the following is a priority nursing action in caring for an organ donor?