A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in a sitting position

Examine the client for areas of skin breakdown

Check the client's bladder for distention

Check the client for a fecal impaction

Answer and Explanation

The Correct Answer is A

Choice A reason:Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia²³.

Choice B reason:While examining for skin breakdown is important, it is not the first action to take when autonomic dysreflexia is suspected.

Choice C reason:Checking the bladder for distention is a critical step, but it should be done after positioning the client to address immediate blood pressure concerns.

Choice D reason:Checking for fecal impaction is also important but follows the initial step of positioning the client to manage blood pressure.

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Correct Answer is A

Explanation

Choice A reason: Administering oxygen therapy is the first and immediate intervention for a client with a pulmonary embolism to address hypoxemia.

Choice B reason: Starting an IV infusion of Lactated Ringer's is important for fluid resuscitation but is not the first intervention for pulmonary embolism.

Choice C reason: Initiating cardiac monitoring is important for observing the client's heart function but comes after ensuring the client is receiving adequate oxygen.

Choice D reason: Giving morphine IV may be used for pain management in pulmonary embolism but is not the first-line intervention.

A. Anorexia B. Weight gain C. Distended abdomen D. Dyspnea

Correct Answer is D

Explanation

Choice A reason: Anorexia, or loss of appetite, is not typically a direct manifestation of left-sided heart failure. While it can be associated with many medical conditions and may occur in the context of heart failure due to overall decreased well-being, it is not a specific indicator of left-sided heart failure.

Choice B reason: Weight gain can be associated with heart failure, but it is more commonly a sign of right-sided heart failure, where fluid accumulates in the body tissues, causing swelling and weight increase. In left-sided heart failure, weight gain is not as prominent because the primary issue is the backup of blood into the lungs, not fluid retention in the tissues.

Choice C reason: A distended abdomen can occur in heart failure due to fluid accumulation; however, it is more characteristic of right-sided heart failure, where the failure of the right ventricle leads to systemic congestion, including the abdominal area. In left-sided heart failure, the primary effect is on the lungs, not the abdomen.

Choice D reason: Dyspnea, or difficulty breathing, is a hallmark symptom of left-sided heart failure. It occurs due to the backup of blood in the pulmonary circulation, which leads to pulmonary congestion and reduced oxygen exchange. Patients may experience shortness of breath, especially during exertion or when lying flat (orthopnea), and may wake up at night with shortness of breath (paroxysmal nocturnal dyspnea).

Left-sided heart failure, often caused by conditions like valvular heart disease, leads to a decrease in the heart’s ability to pump blood effectively. This results in a buildup of pressure in the lungs, manifesting as dyspnea, which is an important symptom for nurses and other healthcare providers to recognize and manage promptly.

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A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Correct Answer is A

Explanation

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

Correct Answer is D

Explanation

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

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