A nurse assesses a patient with a spinal cord injury at level T5. The patient's blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first in response to this complication?

Palpate the bladder for distention.

Initiate oxygen via a nasal cannula.

Place the patient in a supine position.

Administer a prescribed beta-blocker.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Palpating the bladder for distention is the first action the nurse should take. The patient's symptoms suggest autonomic dysreflexia, a condition that can be triggered by bladder distention. Relieving the distention can help resolve the hypertensive crisis.

Choice B reason:

Initiating oxygen via a nasal cannula may be necessary if the patient is experiencing respiratory distress, but it is not the primary intervention for autonomic dysreflexia. The focus should be on identifying and resolving the triggering cause.

Choice C reason:

Placing the patient in a supine position is contraindicated in autonomic dysreflexia as it can worsen the condition by further increasing blood pressure. The patient should be positioned upright if tolerated.

Choice D reason:

Administering a prescribed beta-blocker may help lower blood pressure, but it is not the first action. The underlying cause of autonomic dysreflexia must be addressed to prevent recurrence.

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Correct Answer is A

Explanation

Choice A reason:

Hypoxia not responsive to oxygen therapy is a hallmark early sign of ARDS. ARDS is characterized by acute onset of hypoxemia that does not improve with supplemental oxygen. This refractory hypoxemia is due to severe inflammation and increased permeability of the alveolar-capillary barrier, leading to pulmonary edema and impaired gas exchange.

Choice B reason:

Elevated lactate levels can indicate tissue hypoxia and metabolic stress, which are concerning findings in critically ill patients. However, elevated lactate is not specific to ARDS and can be seen in various conditions, including sepsis and shock. It is not the primary early indicator of ARDS.

Choice C reason:

Metabolic alkalosis is not typically associated with ARDS. ARDS usually involves respiratory failure, which may lead to respiratory acidosis. Metabolic alkalosis can occur in other conditions, such as excessive loss of gastric acid or diuretic use, but it is not an early sign of ARDS.

Choice D reason:

Severe, unexplained electrolyte imbalance can occur in critically ill patients but is not specific to ARDS. Electrolyte imbalances can result from various factors, including fluid shifts, renal dysfunction, and medication effects. These imbalances do not serve as an early diagnostic indicator of ARDS.

A. Serum blood glucose of 128 mg/dL B. Blood pressure of 83/51 mmHg C. Hemoglobin level of 13 g/dL D. Core body temperature of 97.8 degrees F

Correct Answer is B

Explanation

Choice A reason:

A serum blood glucose level of 128 mg/dL is slightly elevated but not immediately concerning in the context of organ donation. Blood glucose levels can be managed with insulin if necessary, and this value does not indicate an acute issue requiring immediate intervention.

Choice B reason:

A blood pressure of 83/51 mmHg is critically low and requires immediate action. Low blood pressure can compromise organ perfusion and oxygen delivery, potentially leading to organ damage. In the context of organ donation, maintaining adequate perfusion pressure is essential to ensure the viability of the organs for transplantation.

Choice C reason:

A hemoglobin level of 13 g/dL is within the normal range and does not require immediate intervention. Hemoglobin levels are important for oxygen-carrying capacity but are not the priority concern six hours before organ harvesting if the value is within normal limits.

Choice D reason:

A core body temperature of 97.8 degrees F is slightly below normal but not immediately alarming. Mild hypothermia can be addressed with warming measures, and this temperature does not indicate a critical issue that requires urgent action.

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A nurse assesses a patient with a spinal cord injury at level T5. The patient's blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first in response to this complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

Correct Answer is A

Explanation

The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patient's organs. Which assessment finding requires immediate action by the nurse?

Correct Answer is B

Explanation

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