Nokea
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer?
- A. Ibuprofen (Advil)
- B. Methylprednisolone (Medrol)
- C. Atropine sulfate
- D. Etanercept (Enbrel)
Correct Answer: B
Rationale: Methylprednisolone is administered within the first 8 hours of a spinal cord injury to reduce inflammation and improve motor and sensory function. The other medications are not indicated for acute spinal cord injury.
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A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this work plan care?
- A. Encourage the client to stretch the back by reaching toward the toes.
- B. Massage the affected area with ice twice a day.
- C. Apply a heating pad for 20 minutes at least four times daily.
- D. Advise the client to avoid warm baths or showers.
Correct Answer: C
Rationale: Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
- A. Assess level of consciousness.
- B. Obtain vital signs.
- C. Administer oxygen therapy.
- D. Evaluate respiratory status.
Correct Answer: D
Rationale: The first priority for a client with a cervical spinal cord injury is to assess respiratory status and airway patency, as these injuries can compromise breathing. Other assessments follow after ensuring airway and breathing are stable.
A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test?
- A. Screen for metal implants or devices.
- B. Implement nothing by mouth (NPO) status for 8 hours.
- C. Administer a sedative to reduce anxiety.
- D. Ensure the client has an empty bladder.
Correct Answer: A
Rationale: Screening for metal implants or devices is critical before an MRI to prevent harm due to magnetic fields. NPO status, sedation, and bladder emptying are not typically required unless specified.
A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should the nurse address first?
- A. Associated stridor.
- B. Weak pedal pulses.
- C. Difficulty breathing.
- D. Inability to shrug shoulders.
Correct Answer: C
Rationale: Difficulty breathing indicates a potential airway obstruction, possibly due to postoperative swelling, which is a priority. Stridor and difficulty swallowing are also concerns but maintaining an airway takes precedence. Weak pedal pulses and inability to shrug shoulders are less urgent.
A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education?
- A. Participate in an exercise program to strengthen muscles.
- B. Purchase a mattress that allows you to adjust the firmness.
- C. Wear flat instead of high-heeled shoes to work each day.
- D. Keep your weight within 20% of your ideal body weight.
Correct Answer: A
Rationale: Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.