A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?
Administer a nitrate antihypertensive.
Obtain the client's heart rate.
Assess the client for bladder distention.
Place the client in a high-Fowler's position.
The Correct Answer is D
Choice A Reason: This is incorrect because administering a nitrate antihypertensive is not the first action, as it may cause a rapid drop in blood pressure and worsen the client's condition.
Choice B Reason: This is incorrect because obtaining the client's heart rate is not the first action, as it does not address the cause of autonomic dysreflexia or relieve the symptoms.
Choice C Reason: This is incorrect because assessing the client for bladder distention is not the first action, as it may take time and delay the treatment of autonomic dysreflexia.
Choice D Reason: This is correct because placing the client in a high-Fowler's position is the first action, as it lowers the blood pressure by promoting venous return and reducing cardiac preload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because a client who is post-CABG and has high cholesterol is not in immediate danger, as atorvastatin is a long-term medication that lowers cholesterol and prevents cardiovascular complications.
Choice B Reason: This is incorrect because a client who has pneumonia and a slightly elevated WBC count is not in immediate danger, as piperacillin is an antibiotic that treats bacterial infections.
Choice C Reason: This is correct because a client who has renal failure and a high serum potassium level is in immediate danger, as sodium polystyrene sulfonate is an emergency medication that lowers potassium and prevents cardiac arrhythmias.
Choice D Reason: This is incorrect because a client who has anemia and a mild hemoglobin deficiency is not in immediate danger, as epoetin alfa is a long-term medication that stimulates red blood cell production and improves oxygen delivery.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because monitoring the client's electrolyte levels is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Choice B Reason: This is correct because suctioning saliva from the client's mouth is the highest priority, as it prevents airway obstruction and aspiration, which can lead to respiratory distress and infection.
Choice C Reason: This is incorrect because recording the client's intake and output is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Choice D Reason: This is incorrect because performing passive range of motion on each extremity is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
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