A nurse is caring for a client who has a spinal cord injury.
Nurses' Notes 0600:
Adventitious lung sounds auscultated in lower lobes bilaterally. Spirometry encouraged. Cough productive for clear sputum.
1000:
Cough productive for clear sputum following incentive spirometry and coughing exercises. Face and neck flushed. Client reports headache.
Abdomen distended. Last bowel movement was 2 days ago with hard stool. Provider Prescriptions
Nifedipine 30 mg PO for blood pressure greater than 150/100 mm Hg and notify provider Acetaminophen 650 mg PO q4 hr PRN pain
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
Administer nifedipine
Assess blood pressure every 15 min.
Perform suctioning.
Assess for urinary retention.
Place client in supine position.
Withhold pain medication for headache until other manifestations resolve.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Anticipated actions for the client include:
- A. Administer nifedipine.
- B. Assess blood pressure every 15 minutes.
- D. Assess for urinary retention.
Contraindicated actions for the client include:
- C. Perform suctioning (since there is no indication or information suggesting the need for suctioning).
- E. Place client in supine position (as it might worsen the symptoms).
- F. Withhold pain medication for headache until other manifestations resolve (it's important to address the headache promptly, especially if acetaminophen is prescribed for pain relief).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. It is recommended to allow at least 1-2 minutes of rest between suction passes to minimize the risk of hypoxia and injury to the airway.
B. Incorrect. Suction is typically applied for 10-15 seconds while withdrawing the catheter to prevent hypoxia and trauma to the airway.
C. Incorrect. Coughing during suctioning can cause the client to aspirate secretions, which can be dangerous. The suctioning should be done quickly and efficiently without disturbing the client's airway.
D. Incorrect. The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.
Correct Answer is B
Explanation
A. Incorrect. A pale appearance and fluid deficit of 30 mL over 24 hours might require intervention but is not as critical as sunken fontanels and dry mucous membranes.
B. Correct. Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.
C. Incorrect. A slightly elevated temperature and an increased pulse rate are common responses to infection and fever in infants.
D. Incorrect. Decreased appetite and irritability can be expected in infants with gastroenteritis and are not as concerning as signs of dehydration.
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