A nurse is caring for a client who has a spinal cord injury.
Nurses' Notes 0600:
Adventitious lung sounds auscultated in lower lobes bilaterally. Spirometry encouraged. Cough productive for clear sputum.
1000:
Cough productive for clear sputum following incentive spirometry and coughing exercises. Face and neck flushed. Client reports headache.
Abdomen distended. Last bowel movement was 2 days ago with hard stool. Provider Prescriptions
Nifedipine 30 mg PO for blood pressure greater than 150/100 mm Hg and notify provider Acetaminophen 650 mg PO q4 hr PRN pain
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
Administer nifedipine
Assess blood pressure every 15 min.
Perform suctioning.
Assess for urinary retention.
Place client in supine position.
Withhold pain medication for headache until other manifestations resolve.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Anticipated actions for the client include:
- A. Administer nifedipine.
- B. Assess blood pressure every 15 minutes.
- D. Assess for urinary retention.
Contraindicated actions for the client include:
- C. Perform suctioning (since there is no indication or information suggesting the need for suctioning).
- E. Place client in supine position (as it might worsen the symptoms).
- F. Withhold pain medication for headache until other manifestations resolve (it's important to address the headache promptly, especially if acetaminophen is prescribed for pain relief).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Postural drainage is usually performed multiple times a day, usually three to four times, to effectively mobilize respiratory secretions.
B. Incorrect. Percussions are typically performed using cupped hands to create vibrations. Holding the hand flat would not produce the desired effect.
C. Bronchodilator should be administered PRIOR to procedure if prescribed
D. Postural drainage should be performed before meals or at least 1-2 hours after meals to prevent vomiting or aspiration.
Correct Answer is A
Explanation
A. Correct. Performing a sterile dressing change falls within the scope of practice for a licensed practical nurse (LPN).
B. Incorrect. Discharge teaching often involves complex information and considerations, which are typically better suited for a registered nurse.
C. Incorrect. An admission assessment requires comprehensive assessment skills that are typically performed by registered nurses.
D. Incorrect. Completing assessments related to complex neurological changes, such as the Glasgow Coma Scale for a stroke, is typically within the scope of a registered nurse.
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