A nurse is caring for a patient who has a T-4 spinal cord injury. Which of the following patient findings should the nurse identify as placing the at risk for developing autonomic dysreflexia?

The patient states having nasal congestion.

The patient's blood pressure becomes elevated.

The patient's bladder becomes distended.

The patient states having a severe headache.

Answer and Explanation

The Correct Answer is C

A. The patient states having nasal congestion. – Incorrect. Nasal congestion is a symptom of autonomic dysreflexia, not a trigger.

B. The patient’s blood pressure becomes elevated. – Incorrect. Hypertension is a symptom of autonomic dysreflexia, not the cause.

C. The patient’s bladder becomes distended. – Correct Answer. Bladder distention is the most common trigger of autonomic dysreflexia, a life-threatening condition causing sudden hypertension, bradycardia, and severe headache. Immediate intervention is needed, such as catheterizing the bladder.

D. The patient states having a severe headache. – Incorrect. A severe headache is a symptom of autonomic dysreflexia, not a cause.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Infuse the transfusion at a rate of 200 mL/hr. – Incorrect. The initial infusion should be slow (e.g., 75-100 mL/hr) to monitor for reactions.

B. Check the patient's vital signs every hour during the transfusion. – Correct Answer. Frequent monitoring is necessary to detect adverse reactions, such as fever or hypotension.

C. Leave the patient 5 minutes after beginning the transfusion. – Incorrect. The nurse should remain with the patient for the first 15 minutes, as most transfusion reactions occur early.

D. Flush the blood tubing with dextrose 5% in water. – Incorrect. Only normal saline should be used to flush blood tubing, as dextrose can cause hemolysis.

A. Performing hand hygiene before, during, and after direct contact with the patient B. Encouraging the patient to consume a high-protein diet C. Changing the patient's bed linens each day D. Do not allow any visitors in the patient's room

Correct Answer is A

Explanation

A. Proper hand hygiene disrupts the transmission of pathogens and is the primary infection control strategy.

B. A high-protein diet helps with recovery but does not directly prevent transmission.

C. While hygiene is important, daily linen changes are not the primary preventive measure.

D. Restricting visitors is only necessary for highly contagious infections.

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 patient who has a T-4 spinal cord injury. Which of the following patient findings should the nurse identify as placing the at risk for developing autonomic dysreflexia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to initiate a transfusion of packed RBC for a patient who has anemia. Which of the following actions should the plan to nurse take?

Correct Answer is B

Explanation

A nurse is caring for a patient who has an infection. The nurse should use which of the following strategies to prevent the transmission of the patient's infection?

Correct Answer is A

Explanation

The nurse is evaluating care provided to a patient with type 2 diabetes mellitus. Which data indicates that the patient is managing the disease process effectively?

A nurse is admitting a child who has leukemia. Which of the following patients should the nurse place in the same room with this child?

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

A nurse in an emergency department is caring for a patient who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?

A nurse is caring for a patient with Alzheimer's Disease who falls frequently. Which of the following actions should the nurse take first to keep the patient safe?

An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/μL during chemotherapy is to

Which of the following evaluation data would the nurse recognize that a patient with hyperosmolar hyperglycemic syndrome (HHS) has improved during the first 24 hours upon admission to the hospital?

A patient with diabetes is admitted with symptoms of diabetic ketoacidosis (DKA). Which type of insulin IV should a nurse expect to administer?