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

The property of the drugs that, if shared by both, indicates a need to closely monitor the client for drug toxicity is:

Highly protein bound.

When a drug is highly protein bound, it means that a significant portion of the drug molecules bind to proteins in the bloodstream. This binding can affect the availability and distribution of the drug in the body. If two drugs are highly protein bound and administered together, they may compete for binding sites on the proteins, leading to increased levels of unbound (free) drug in the bloodstream. This can result in higher drug concentrations and an increased risk of drug toxicity.

Closely monitoring the client for drug toxicity is necessary when drugs are highly protein bound because there is a potential for increased drug levels and associated adverse effects. Monitoring for signs and symptoms of drug toxicity, as well as routine laboratory tests to assess liver and kidney function, may be necessary in these cases.

The other properties listed do not necessarily indicate a need for closer monitoring for drug toxicity:

Low bioavailability refers to the fraction of an administered dose that reaches the systemic circulation in an active form. While low bioavailability can affect the effectiveness of a drug, it does not directly imply a need for closer monitoring for drug toxicity.
Short half-life refers to the time it takes for half of the drug concentration in the body to be eliminated. While drugs with short half-lives may require more frequent dosing, this property does not inherently suggest a need for closer monitoring for drug toxicity.
High therapeutic index indicates a wide margin of safety for a drug, meaning that the effective dose is significantly lower than the toxic dose. A high therapeutic index implies that the drug has a wide safety margin and is less likely to cause drug toxicity.

A. Apply baby lotion to the skin twice daily. B. Bathe the child daily with bath oil. C. Allow the child to wear only 100% cotton clothing. D. Keep the nails trimmed short.

Correct Answer is D

Explanation

Keeping the child's nails trimmed short helps minimize the risk of further skin damage and infection resulting from scratching. It reduces the likelihood of breaking the skin and causing bleeding. This preventive measure can help protect the child's skin and promote healing. It is important to combine nail trimming with other appropriate interventions for managing eczema, such as moisturizing the skin, avoiding irritants, and following the healthcare provider's recommendations for treatment.

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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 planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity?

Correct Answer is C

Explanation

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

Correct Answer is D

Explanation

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective?

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

When should the nurse conduct an Allen's test?

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

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