Nursing 301 Exam 4 – Questions With Fully
Explained Solutions
Save
Terms in this set (173)
How frequently should cervical collar every 8 hours
care be done?
When performing cervical collar care, head of bed
where should the person who is
stabilizing the head stand while
cleaning the skin under the collar?
When an extrication collar is placed, within 6 hours
within how many hours should it be
changed to an Aspen or Miami J
collar?
Preferred medication to stop a seizure lorazepam (Ativan)
a controlled substance that is
refrigerated
remember to dilute equal parts of
saline - draw med first and then saline
_______ interventions: seizure interventions
safety - side rail padding
left lateral recumbent position with
HOB flat
pillows under the head
loosen any tight or restricting clothing
apply oxygen - 100% nonrebreather
mask
administer lorazepam
have suction ready at the bedside
,true or false: only give Ativan while true
the seizure is occurring
what is lorazepam's (Ativan) reversal flumazenil (Romazicon)
agent? (hint...the reversal agent for all
benzodiazepines)
placed in the patient's skull to pull the cervical tongs
vertebrae apart
two types: Crutchfield, Gardner-Wells
a short-term solution to reduce
swelling before surgery
do not let the weights rest on the
floor - must be continuous traction
(no breaks)
pin care as ordered to prevent
infection
placed in the patient's skull to stabilize halo
alignment of the cervical spine
more of a long-term solution as it can
be in place for 6 months
do not drive - patient cannot turn the
head
pin care as ordered to prevent
infection (half-strength hydrogen
peroxide or NS)
do not grab onto the bars when
turning a patient with this device
*lift up plastic to do CPR if needed
,placed on all trauma patients with cervical collars
unknown possible cervical spine
issues
6 hours to switch to an Aspen collar or
Miami J collar
do not remove until it is known that "C
spines are clear and can remove the
collar"
skin care must be performed at a
minimum of every 8 hours
a type of cervical collar that is not Miami J collar
used as often due to its high risk for
skin breakdown
the preferred cervical collar Aspen collar
The nurse is caring for a client in a C
halo traction device. Which of the
following demonstrates proper
management of the device?
A. Have the client remove the halo
traction device for one hour daily
B. Use the halo device to reposition
the client's head
C. Attach the device wrench to the
client's head of bed
D. Cleanse the halo traction pins with
soapy water
, A patient with a spinal cord injury (SCI) B, D, E
is admitted to the unit and placed in
traction. Which of the following
actions is the nurse responsible for
when caring for this patient? SATA
A. Modifying the traction weights as
needed
B. Assessing the patient's skin integrity
C. Releasing the traction for 30
minutes each morning
D. Administering pain medication
E. Providing passive range of motion
Your patient has entered the post ictal C
stage for seizures. The patient's
seizure presented with an aura
followed by body stiffening and then
recurrent jerking. The patient had
incontinence and bleeding in the
mouth from injury to the tongue. What
is an expected finding in this stage
based on the type of seizure this
patient experienced?
A. Crying and anxiety
B. Immediate return to baseline
behavior
C. Sleepy, headache, and soreness
D. Unconsciousness
Explained Solutions
Save
Terms in this set (173)
How frequently should cervical collar every 8 hours
care be done?
When performing cervical collar care, head of bed
where should the person who is
stabilizing the head stand while
cleaning the skin under the collar?
When an extrication collar is placed, within 6 hours
within how many hours should it be
changed to an Aspen or Miami J
collar?
Preferred medication to stop a seizure lorazepam (Ativan)
a controlled substance that is
refrigerated
remember to dilute equal parts of
saline - draw med first and then saline
_______ interventions: seizure interventions
safety - side rail padding
left lateral recumbent position with
HOB flat
pillows under the head
loosen any tight or restricting clothing
apply oxygen - 100% nonrebreather
mask
administer lorazepam
have suction ready at the bedside
,true or false: only give Ativan while true
the seizure is occurring
what is lorazepam's (Ativan) reversal flumazenil (Romazicon)
agent? (hint...the reversal agent for all
benzodiazepines)
placed in the patient's skull to pull the cervical tongs
vertebrae apart
two types: Crutchfield, Gardner-Wells
a short-term solution to reduce
swelling before surgery
do not let the weights rest on the
floor - must be continuous traction
(no breaks)
pin care as ordered to prevent
infection
placed in the patient's skull to stabilize halo
alignment of the cervical spine
more of a long-term solution as it can
be in place for 6 months
do not drive - patient cannot turn the
head
pin care as ordered to prevent
infection (half-strength hydrogen
peroxide or NS)
do not grab onto the bars when
turning a patient with this device
*lift up plastic to do CPR if needed
,placed on all trauma patients with cervical collars
unknown possible cervical spine
issues
6 hours to switch to an Aspen collar or
Miami J collar
do not remove until it is known that "C
spines are clear and can remove the
collar"
skin care must be performed at a
minimum of every 8 hours
a type of cervical collar that is not Miami J collar
used as often due to its high risk for
skin breakdown
the preferred cervical collar Aspen collar
The nurse is caring for a client in a C
halo traction device. Which of the
following demonstrates proper
management of the device?
A. Have the client remove the halo
traction device for one hour daily
B. Use the halo device to reposition
the client's head
C. Attach the device wrench to the
client's head of bed
D. Cleanse the halo traction pins with
soapy water
, A patient with a spinal cord injury (SCI) B, D, E
is admitted to the unit and placed in
traction. Which of the following
actions is the nurse responsible for
when caring for this patient? SATA
A. Modifying the traction weights as
needed
B. Assessing the patient's skin integrity
C. Releasing the traction for 30
minutes each morning
D. Administering pain medication
E. Providing passive range of motion
Your patient has entered the post ictal C
stage for seizures. The patient's
seizure presented with an aura
followed by body stiffening and then
recurrent jerking. The patient had
incontinence and bleeding in the
mouth from injury to the tongue. What
is an expected finding in this stage
based on the type of seizure this
patient experienced?
A. Crying and anxiety
B. Immediate return to baseline
behavior
C. Sleepy, headache, and soreness
D. Unconsciousness
