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.

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Correct Answer is C

Explanation

Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of lung tissue and loss of elasticity in the alveoli. This leads to poor gas exchange, specifically the reduced ability of oxygen to enter the bloodstream and carbon dioxide to be eliminated from the body. Impaired gas exchange can result in hypoxemia and hypercapnia, leading to symptoms such as shortness of breath, fatigue, and decreased exercise tolerance.

While self-care deficit, activity intolerance, and ineffective airway clearance are all potential complications associated with emphysema, impaired gas exchange is the priority due to its direct impact on the client's oxygenation and overall respiratory function.

Addressing impaired gas exchange and optimizing oxygenation is essential to support the client's respiratory health and prevent further complications. Management strategies for impaired gas exchange may include administering supplemental oxygen, implementing respiratory treatments to improve lung function, and providing education on breathing techniques and energy conservation.

A. An adult who is in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours. B. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection. C. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery. D. An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.

Correct Answer is B

Explanation

A) Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B) Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C) Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D) Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.

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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

The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication?

Correct Answer is C

Explanation

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

Correct Answer is B

Explanation

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The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900. What nursing action is most important?

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