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 {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
Pyrexia, also known as fever, refers to an elevated body temperature that is above the normal range. The normal body temperature is typically around 37°C (98.6°F), and a temperature of 38.4°C (101.1°F) indicates a fever.
Alternative Choices:
1. "tachycardia" due to "heart rate of 92/min"
- Incorrect. Tachycardia refers to an abnormally high heart rate, usually above 100 beats per minute (bpm) in adults. A heart rate of 92/min is within normal limits and does not qualify as tachycardia.
2. "hypertension" due to "blood pressure of 130/78 mm Hg"
- Incorrect. Hypertension is defined as having a blood pressure reading consistently above 140/90 mm Hg. The reading of 130/78 mm Hg falls into the elevated category but does not reach the threshold for hypertension.
3. "respiratory distress" due to "respiratory rate of 18/min"
- Incorrect. A respiratory rate of 18 breaths per minute is considered normal for adults, so this finding does not indicate respiratory distress.
4. "obesity" due to "current BMI of 29.9"
- Partially correct. A BMI of 29.9 places the client in the "overweight" category, just below the threshold for obesity (BMI of 30 or higher). However, the presence of pyrexia is the more immediate clinical concern based on the provided vital signs.
Correct Answer is E, B, D,C,A
Explanation
2. E. Turn on the suction and set the pressure.
1. B. Don sterile gloves.
3. D. Insert the catheter during the client's inspiration.
4. C. Apply suction while rotating the catheter.
5. A. Rinse the catheter to remove secretions.
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