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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.

A.

Administer nifedipine

B.

Assess blood pressure every 15 min.

C.

Perform suctioning.

D.

Assess for urinary retention.

E.

Place client in supine position.

F.

Withhold pain medication for headache until other manifestations resolve.

Answer and Explanation

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).


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

The client is at highest risk for developing mastitis evidenced by the client's visible cracknoted on left nipple

Correct Answer is A

Explanation

A. Correct. Influenza immunization is recommended for pregnant individuals, and it can be given at any time during pregnancy, especially during flu season.
B. Incorrect. The hepatitis B immunization is safe during pregnancy and can be administered if indicated, regardless of breastfeeding status.
C. Incorrect. Rubella immunization is not recommended during pregnancy due to potential risks to the fetus. It should be given prior to pregnancy or after delivery.
D. Incorrect. Varicella immunization is also not recommended during pregnancy due to potential risks. It should be administered before pregnancy or after delivery if needed.

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