A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache.
The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Administer a nitrate antihypertensive.

Assess the client for bladder distention.

Obtain the client's heart rate.

Place the client in a high-Fowler's position.

Answer and Explanation

The Correct Answer is D

Prioritizing interventions for autonomic dysreflexia in quadriplegic clients requires understanding the physiological response to noxious stimuli below the injury level. Critical thinking is applied to determine the most immediate action to lower dangerous hypertensive levels and prevent intracranial hemorrhage or seizures.

Choice A rationale

Nitrates are used to manage severe hypertension in autonomic dysreflexia, but pharmacological intervention is not the first step. Non-pharmacological measures to reduce blood pressure should be attempted immediately before administering medications to the client to ensure safety.

Choice B rationale

Assessing for bladder distention is vital because it is the most common trigger for autonomic dysreflexia. However, physiological stabilization via positioning must occur before or simultaneously with the search for the underlying cause to prevent immediate vascular complications.

Choice C rationale

Monitoring the heart rate is necessary as bradycardia often accompanies the hypertensive surge in autonomic dysreflexia. While important for assessment, obtaining vital signs does not actively lower the blood pressure or address the immediate risk of a stroke.

Choice D rationale

Placing the client in a high-Fowler's position is the priority action because it utilizes gravity to cause orthostatic pooling of blood in the lower extremities. This immediate intervention helps decrease the dangerously high blood pressure and reduces intracranial pressure..

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Hyperkalemia management involves identifying medications that facilitate the removal of potassium from the body. Understanding the mechanism of action of various renal and GI medications is necessary. This prevents cardiac arrest by lowering potassium toward the 3.5 to 5.0 mEq/L range.

Choice A rationale

This medication is a cation exchange resin that works in the intestine. It exchanges sodium ions for potassium ions, allowing the potassium to be excreted through the feces. It is specifically indicated for treating high serum potassium levels.

Choice B rationale

Lactulose is an osmotic laxative primarily used to reduce serum ammonia levels in clients with hepatic encephalopathy. It promotes the excretion of ammonia through the stool but has no significant effect on lowering serum potassium levels.

Choice C rationale

This medication is an erythropoiesis stimulating agent used to treat anemia associated with chronic kidney disease. It stimulates red blood cell production in the bone marrow but does not influence electrolyte levels or treat acute hyperkalemia.

Choice D rationale

Sevelamer is a phosphate binder used to manage hyperphosphatemia in clients with chronic kidney disease. It prevents the absorption of dietary phosphorus in the gut but does not have a mechanism to lower serum potassium concentrations.

A. Administer oxygen therapy. B. Give morphine IV. C. Initiate cardiac monitoring. D. Start an IV infusion of lactated Ringer's

Correct Answer is A

Explanation

Pulmonary embolism disrupts the ventilation-perfusion ratio, leading to sudden hypoxemia and respiratory distress. Prioritizing interventions requires applying the airway, breathing, circulation framework. Knowledge of gas exchange and emergency protocols is necessary to stabilize the client and maintain systemic cellular oxygenation.

Choice A rationale

Oxygen administration is the priority to treat hypoxemia caused by the physiological dead space created by the embolism. Improving arterial oxygen saturation supports myocardial and cerebral function while reducing the workload of the right ventricle during obstruction.

Choice B rationale

Morphine acts as an analgesic and vasodilator which can reduce anxiety and preload. However, it does not address the primary physiological threat of impaired gas exchange. Breathing and oxygenation must be stabilized before managing pain or sedation.

Choice C rationale

Cardiac monitoring identifies arrhythmias and right-sided heart strain associated with pulmonary hypertension. While diagnostic, it is a secondary action that follows the restoration of oxygenation. Assessment tools should not delay the implementation of life-saving oxygen therapy.

Choice D rationale

Lactated Ringer's is used for volume expansion and electrolyte replacement. In pulmonary embolism, excessive fluid can worsen right ventricular failure and pulmonary edema. Circulatory support is important but remains secondary to correcting the immediate life-threatening respiratory deficit..

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer?

Correct Answer is A

Explanation

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 assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

The physician prescribes ticarcillin 35 mg IV every 4 hours for a client post kidney transplant. The client weighs 14 lbs. The nursing drug reference recommends a maximum of 20-30 mg/kg/day. Is the ordered dose for this client safe? Yes or No.

A client with a traumatic brain injury (TBI) presents to the emergency department with a Glasgow Coma Scale (GCS) score of 10. What should be the nurse's primary focus in this situation?

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

The nurse plans care for a client with a brain tumor who developed a syndrome of inappropriate antidiuretic hormone. Which interventions should the nurse include in the plan? Select all that apply.

A client with a full-thickness burn to the front of the left leg underwent skin grafting. The nurse notes pain 6/10, dressing dry and intact, and slight edema at the graft site. Which action is the priority?

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache.
The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?