A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take.
(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Administer an antihypertensive medication intravenously.
Confirm that the client's bladder is empty.
Indicate the risk for autonomic dysreflexia in the client's medical record.
Place the client in an upright sitting position.
The Correct Answer is D,B,A,C
Step D (Place the client in an upright sitting position): Elevating the client's head and upper body to an upright position helps to reduce blood pressure by promoting venous pooling in the lower extremities.
Step B (Confirm that the client's bladder is empty): Autonomic dysreflexia is often triggered by bladder distention or urinary retention. By confirming and addressing urinary issues promptly, the nurse can remove the triggering stimulus.
Step A (Administer an antihypertensive medication intravenously): In severe cases where blood pressure remains dangerously high despite other interventions, such as positioning and addressing bladder issues, antihypertensive medications may be necessary to lower blood pressure quickly and prevent complications.
Step C (Indicate the risk for autonomic dysreflexia in the client's medical record): Documentation of the occurrence of autonomic dysreflexia, its triggers, and interventions used is essential for continuity of care. It informs other healthcare providers about the client's condition and helps in implementing preventive strategies.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}
Explanation
Obtain client weight twice daily
Anticipated: This intervention is anticipated. Monitoring the client's weight is crucial when they are receiving Total Parenteral Nutrition (TPN) to assess for fluid status, nutritional adequacy, and response to therapy. It helps in adjusting TPN rates and managing fluid balance.
Have 3 nurses verify the TPN solution prescription
Anticipated: Verifying TPN solution prescription by multiple nurses is a critical safety measure to prevent errors in TPN administration, which can have serious consequences. This ensures that the TPN solution matches the prescribed order in terms of content, concentration, and rate.
Request a prescription for insulin
Anticipated: Given the client's hyperglycemia (fasting blood glucose of 140 mg/dL) and potential exacerbation by TPN administration (which can be rich in glucose), requesting insulin is appropriate. Insulin helps manage blood glucose levels and prevent hyperglycemia, especially important in clients with diabetes or those on TPN.
Request an antibiotic to be administered
Anticipated: The client presents with signs of infection (fever, productive cough, yellow sputum) and crackles auscultated in the lungs, indicating a possible respiratory infection. Requesting antibiotics is essential to treat the infection promptly and prevent further complications.
Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula
Nonessential: The client is currently receiving 2 L/min oxygen via nasal cannula with an oxygen saturation of 90%. Decreasing the oxygen flow may compromise oxygenation further, especially given the crackles and productive cough. It is more appropriate to maintain or potentially increase oxygen support based on the client's oxygen saturation.
Notify provider to increase TPN rate/hr
Contraindicated: The client has diarrhea (3 episodes in the past 4 hours) and an abdominal distension, which may indicate gastrointestinal intolerance to TPN. Increasing the TPN rate could exacerbate diarrhea and worsen fluid and electrolyte imbalances. It is important to address the underlying cause of diarrhea and abdominal symptoms before considering any increase in TPN rate.
Correct Answer is ["C"]
Explanation
A To obtain reliable results, it is generally recommended to collect samples from different areas of the stool across multiple bowel movements rather than from a single sample.
detecting occult blood if it is present in the stool but not evenly distributed throughout. It also helps to reduce the chance of obtaining a false negative result.
C. Urine can interfere with the accuracy of fecal occult blood testing, leading to false positive results. Therefore, any sample that contains visible urine should be discarded to prevent inaccurate test results.
B. While gloves should be worn to maintain standard precautions and prevent direct contact with feces, sterile gloves are not required for this procedure. Standard medical examination gloves are sufficient to ensure hygiene and prevent contamination during sample collection.
D. The guaiac smear should be performed on a small portion of stool obtained from different areas within the bowel movement, not specifically from the outer edge of formed stool. The goal is to sample from different parts to increase the likelihood of detecting any occult blood present.
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