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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["35"]
Explanation
- Step 1: Identify the total volume to be administered. The nurse is scheduled to administer 840 mL of enteral nutrition over a 24-hour period.
- Step 2: Identify the total time over which the volume is to be administered. The total time is 24 hours.
- Step 3: Calculate the rate at which the infusion pump should be set. We can do this by dividing the total volume by the total time:
- Rate = Total Volume ÷ Total Time.
- Rate = 840 mL ÷ 24 hours.
- Calculating the division gives us: Rate = 35 mL/hr.
set the infusion pump to deliver 35 mL/hr.
Correct Answer is C
Explanation
Choice A reason: A fractured femur, while a serious injury, does not inherently contraindicate the use of lipid emulsions. These patients may require additional nutrition if they are unable to eat adequately by mouth, and lipid emulsions can be part of their parenteral nutrition regimen if needed.
Choice B reason: Severe anorexia nervosa is a condition that can lead to malnutrition and may necessitate the use of parenteral nutrition, including lipid emulsions, to provide essential nutrients. However, care must be taken to avoid refeeding syndrome, a potentially fatal condition that can occur when malnourished patients begin to refeed too quickly.
Choice C reason: Gastrointestinal obstruction is a condition that could be exacerbated by the administration of lipid emulsions. In cases of obstruction, enteral or parenteral nutrition may need to be carefully managed or avoided until the obstruction is resolved to prevent further complications. While lipid emulsions are a valuable component of parenteral nutrition, their use must be carefully considered in the context of the patient’s overall clinical condition. In the case of gastrointestinal obstruction, the nurse would be most concerned about the prescription of a lipid emulsion due to the potential for exacerbating the obstruction and complicating the patient’s condition.
Choice D reason: Chronic diarrhea and vomiting can lead to dehydration and electrolyte imbalances, but they do not directly contraindicate the use of lipid emulsions. However, the underlying cause of these symptoms should be addressed, and fluid and electrolyte balance should be carefully monitored.
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