A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?
Place the client in a sitting position
Examine the client for areas of skin breakdown
Check the client's bladder for distention
Check the client for a fecal impaction
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 dysreflexia²³.
Choice B reason:While examining for skin breakdown is important, it is not the first action to take when autonomic dysreflexia is suspected.
Choice C reason:Checking the bladder for distention is a critical step, but it should be done after positioning the client to address immediate blood pressure concerns.
Choice D reason:Checking for fecal impaction is also important but follows the initial step of positioning the client to manage blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:Bubbling in the water seal chamber with exhalation can be normal, indicating that air is being evacuated from the pleural space.
Choice B reason:Crepitus, or subcutaneous emphysema, can indicate that air is leaking into the tissue around the chest tube site, which is a serious complication that requires immediate attention.
Choice C reason:
Movement of the trachea toward the unaffected side can indicate tension pneumothorax, a life-threatening condition that also requires immediate attention.
Choice D reason:If the eyelets of the chest tube are not visible, it may simply mean that the tube is inserted fully, which is not an immediate cause for concern unless other symptoms are present.
Correct Answer is B
Explanation
Choice A reason: The GFR does not recover during the oliguric phase; instead, it is typically reduced, reflecting impaired kidney function.
Choice B reason: Urine output of less than 400 mL per 24 hours is characteristic of the oliguric phase of AKI. This phase can last from 1 to 7 days after kidney injury and is a crucial time for monitoring and managing the patient's fluid and electrolyte balance.
Choice C reason: BUN and creatinine levels do not decrease during the oliguric phase. They usually increase due to reduced kidney function and the inability to excrete these waste products.
Choice D reason: Renal function is not reestablished during the oliguric phase. This phase is part of the course of AKI where renal function is at its lowest, and recovery has not yet begun.
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