Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

Administer a prescribed PRN dose of hydralazine.

Assess the client's blood pressures every 15 minutes.

Teach the client to recognize the symptoms of dysreflexia.

Relieve any kinks or obstruction in the client's Foley tubing.

Answer and Explanation

The Correct Answer is D

A)   This can be done if initial non-pharmacological interventions do not relieve symptoms, but it is not the first step.
B)   Monitoring blood pressure is important, but it is secondary to removing the stimulus causing the dysreflexia.
C)   Incorrect- While education is important for long-term management, the client is currently experiencing symptoms that need immediate attention. The priority is to assess and address the current symptoms.
D)   The client is likely experiencing autonomic dysreflexia, characterized by a sudden and severe increase in blood pressure, flushing, headache, and other symptoms triggered by a noxious stimulus below the level of injury. The first step in managing autonomic dysreflexia is to identify and eliminate the triggering stimulus. For clients with a Foley catheter, a common cause of autonomic dysreflexia is bladder distention due to a kinked or obstructed catheter. Relieving any kinks or obstructions in the Foley tubing can immediately alleviate the symptoms.

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 ["200"]

Explanation

To calculate the mL/hour for the erythromycin infusion, we first need to determine the infusion rate in mL/minute.

The infusion is to be completed over 30 minutes, which is equal to 0.5 hours. Next, we divide the total volume (100 mL) by the total time (0.5 hours) to get the infusion rate in mL/hour:

Infusion rate = Total volume / Total time

Infusion rate = 100 mL / 0.5 hours Infusion rate = 200 mL/hour

Therefore, the nurse should program the infusion pump to deliver the erythromycin infusion at a rate of 200 mL/hour.

A. Buttered whole wheat toast and coffee. B. Sausage, poached eggs, and milk. C. Granola, strawberries, and tea. D. Oatmeal, banana, and herbal tea.

Correct Answer is D

Explanation

This breakfast selection is the most appropriate for a 16-year-old with diarrhea. Oatmeal is a bland and easily digestible food that can help to firm up the stool. Bananas are a good source of potassium and can help replace electrolytes that may be lost through diarrhea. Herbal tea is a non-caffeinated option that can help to soothe the digestive system. It is important to avoid foods that are greasy, high in fat, or spicy, as they can worsen diarrhea symptoms.

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

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (DW) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump?

Correct Answer is ["200"]

Explanation

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

Correct Answer is D

Explanation

Patient Data What other treatments might be helpful for this client? Select all that apply.

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure?

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide