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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.

A.

Administer nifedipine

B.

Assess blood pressure every 15 min.

C.

Perform suctioning.

D.

Assess for urinary retention.

E.

Place client in supine position.

F.

Withhold pain medication for headache until other manifestations resolve.

Answer and Explanation

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).


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Related Questions

Correct Answer is A

Explanation

A. Correct. The International Normalized Ratio (INR) is used to monitor the effectiveness of warfarin therapy, which is commonly prescribed to prevent blood clotting. The INR provides information about the client's prothrombin time (PT) in relation to a standardized value.
B. Fibrinogen level measures clotting potential but is not directly related to warfarin therapy monitoring.
C. Activated Partial Thromboplastin Time (aPTT) is used to monitor other anticoagulants like heparin, not warfarin.
D. Platelet count measures the number of platelets in the blood and is not specifically related to warfarin therapy monitoring.

Correct Answer is D

Explanation

A. Alcohol-based cleaning products are flammable and should not be used near oxygen equipment.
B. Petroleum jelly is also flammable and should not be applied to the client's face when using oxygen therapy.
C. Synthetic fabrics cangenerate static electricity, which could potentially lead to a fire hazard in the presence of oxygen.
D. Nail polish remover is flammable and should be avoided near oxygen equipment.

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