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. Encouraging a focus on tertiary health interventions might not address the preventive health needs of the population.
B. Incorrect. While raising awareness about industrial pollution is important, it might not be the primary focus of a public health program in a rural area.
C. Incorrect. Utilizing a nurse from outside the community might not be the most effective approach for understanding the specific health needs and context of the local population.
D. Correct. Providing anticipatory guidance classes to parents through public schools is a community-based preventive approach that can address the health needs of families and children in the area.
Correct Answer is A
Explanation
A. Correct. The child should be instructed to blow into the peak expiratory flow meter as hard and quickly as possible to achieve maximal effort. This provides an accurate measure of peak expiratory flow, which is important in assessing asthma control.
B. Incorrect. The child's body position during testing does not typically affect the accuracy of peak expiratory flow measurements.
C. Incorrect. While recording the average of multiple readings over time is important, the child needs to understand how to perform a single accurate reading first.
D. Incorrect. The tongue is not usually involved in the use of a peak expiratory flow meter.
The child should place their lips tightly around the mouthpiece to create a seal while blowing forcefully into the device.
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