Critical Care Registered Nurse (CCRN) Practice Exam

Which nursing intervention is crucial for a patient with an acute spinal cord injury?

1. Provide pain medication every 4 hours

2. Position the patient flat at all times

3. Regularly monitor vital signs and neuro status

4. Encourage unrestricted fluid intake

The correct answer is: Regularly monitor vital signs and neuro status

Monitoring vital signs and neurological status is crucial for a patient with an acute spinal cord injury due to the potential for life-threatening complications, including respiratory failure, altered hemodynamics, and loss of sensation or movement below the injury level. Changes in vital signs can indicate autonomic dysreflexia, which is a common and potentially dangerous condition that can arise after a spinal cord injury. Close neurological assessments are essential to detect any changes in the patient’s condition promptly. For example, a decline in neurological function might signal worsening injury or the development of secondary complications, such as edema or hemorrhage. Timely recognition of these changes can lead to prompt interventions that are life-saving. While pain management, positioning, and fluid intake are also important aspects of care, they do not carry the same immediate critical relevance as ongoing monitoring, which directly influences patient safety and outcomes. Positioning, for example, may vary based on the type of injury and the clinical situation, whereas regular vital sign checks provide essential information about the patient’s overall stability.