Nursing 301 - Exam 4 Questions And Correct
Answers
1. every 8 hours how frequently should cervical collar care be done?
2. head of bed when performing cervical collar care, where should the person who is
stabilizing the head stand while cleaning the skin under the collar?
3. within 6 hours when an extrication collar is placed, within how many hours should it be
changed to an Aspen or Miami J collar?
4. lorazepam preferred medication to stop a seizure
(Ati- van) a controlled substance that is refrigerated
remember to dilute equal parts of saline - draw med first and then saline
5. seizure interven- interventions:
tions 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
6. true true or false: only give Ativan while the seizure is occurring
7. flumazenil what is lorazepam's (Ativan) reversal agent? (hint...the reversal agent for
(Ro- all ben- zodiazepines)
mazicon)
8. cervical tongs placed in the patient's skull to pull the vertebrae apart
two types: Crutchfield, Gardner-Wells
a short-term solution to reduce swelling before surgery
, Nursing 301 - Exam 4 Questions And Correct
Answers
do not let the weights rest on the floor - must be continuous traction
(no breaks) pin care as ordered to prevent infection
9. halo placed in the patient's skull to stabilize 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
10. cervical collars placed on all trauma patients with 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
11. Miami J collar a type of cervical collar that is not used as often due to its high risk for
skin
breakdown
, Nursing 301 - Exam 4 Questions And Correct
Answers
12. Aspen collar the preferred cervical collar
13. C The nurse is caring for a client in a 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
14. B, D, E A patient with a spinal cord injury (SCI) 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
15. C Your patient has entered the post ictal stage for seizures. The patient's
seizure presented with an aura followed by body stittening and then
recurrent jerking. The patient had incontinence and bleeding in the
, Nursing 301 - Exam 4 Questions And Correct
Answers
mouth from injury to the tongue.
Answers
1. every 8 hours how frequently should cervical collar care be done?
2. head of bed when performing cervical collar care, where should the person who is
stabilizing the head stand while cleaning the skin under the collar?
3. within 6 hours when an extrication collar is placed, within how many hours should it be
changed to an Aspen or Miami J collar?
4. lorazepam preferred medication to stop a seizure
(Ati- van) a controlled substance that is refrigerated
remember to dilute equal parts of saline - draw med first and then saline
5. seizure interven- interventions:
tions 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
6. true true or false: only give Ativan while the seizure is occurring
7. flumazenil what is lorazepam's (Ativan) reversal agent? (hint...the reversal agent for
(Ro- all ben- zodiazepines)
mazicon)
8. cervical tongs placed in the patient's skull to pull the vertebrae apart
two types: Crutchfield, Gardner-Wells
a short-term solution to reduce swelling before surgery
, Nursing 301 - Exam 4 Questions And Correct
Answers
do not let the weights rest on the floor - must be continuous traction
(no breaks) pin care as ordered to prevent infection
9. halo placed in the patient's skull to stabilize 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
10. cervical collars placed on all trauma patients with 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
11. Miami J collar a type of cervical collar that is not used as often due to its high risk for
skin
breakdown
, Nursing 301 - Exam 4 Questions And Correct
Answers
12. Aspen collar the preferred cervical collar
13. C The nurse is caring for a client in a 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
14. B, D, E A patient with a spinal cord injury (SCI) 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
15. C Your patient has entered the post ictal stage for seizures. The patient's
seizure presented with an aura followed by body stittening and then
recurrent jerking. The patient had incontinence and bleeding in the
, Nursing 301 - Exam 4 Questions And Correct
Answers
mouth from injury to the tongue.
