A nurse is caring for a client who has a spinal cord injury and is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in a sitting position

Check the client for a fecal impaction

Examine the client for areas of skin breakdown

Check the blood pressure for discrepancies

Answer and Explanation

The Correct Answer is A

Choice A reason: Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia.

Choice B reason: Checking for a fecal impaction is important as it can be a trigger for autonomic dysreflexia, but it is not the first action to take.

Choice C reason: Examining for areas of skin breakdown is part of ongoing care for clients with spinal cord injuries but is not the immediate priority in autonomic dysreflexia.

Choice D reason: Checking blood pressure is important for monitoring the severity of autonomic dysreflexia, but the first action is to address the positioning of the client to manage the hypertensive crisis.

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Correct Answer is C

Explanation

Choice A reason: The blood should not be infusing for 5 hours as transfusions of packed RBCs should be completed within 2 to 4 hours to minimize the risk of bacterial growth and transfusion reactions.

Choice B reason: Medications should not be administered through the same IV line as blood products due to the risk of reactions and interactions.

Choice C reason: The packed RBCs are indeed connected by Tubing to normal saline, which is used to keep the line open and prevent clotting.

Choice D reason: The drip chamber should not be filled completely with blood as it is necessary to monitor the drip rate and to ensure that air does not enter the line.

A. Elevated B. Stage 1 hypertension C. Stage 2 hypertension D. Normal

Correct Answer is A

Explanation

Choice A reason: A blood pressure reading of 124/79 mm Hg is considered elevated. The normal range for blood pressure is less than 120/80 mm Hg. Elevated blood pressure is when readings consistently range from 120129 systolic and less than 80 mm Hg diastolic.

Choice B reason: Stage 1 hypertension is defined by a systolic blood pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg. The client's blood pressure does not fall into this category.

Choice C reason: Stage 2 hypertension is characterized by a systolic blood pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher. The client's blood pressure is below these levels.

Choice D reason: A normal blood pressure reading is typically below 120/80 mm Hg. Although the client's diastolic pressure is within the normal range, the systolic pressure is above normal, thus it does not qualify as a normal blood pressure reading.

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A nurse is caring for a client who has a spinal cord injury and is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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