A nurse is caring for a client with a C4 spinal cord injury with an indwelling urinary catheter who exhibits signs of autonomic dysreflexia, including a severe headache and hypertension. What should the nurse do first?

Administer an antihypertensive medication to the client.

Place the client in a supine position.

Check the urinary catheter for kinks.

Perform digital rectal stimulation.

Answer and Explanation

The Correct Answer is C

Autonomic dysreflexia is a life-threatening condition that occurs in clients with spinal cord injuries at or above T6 due to an exaggerated autonomic response to a noxious stimulus below the level of injury. It is commonly triggered by bladder distention, bowel impaction, or other irritants. This leads to sudden hypertension, pounding headache, bradycardia, and diaphoresis above the level of injury. Immediate identification and removal of the triggering stimulus is the priority to prevent complications such as stroke or seizures.

Rationale:
A. Administering an antihypertensive medication is not the first action because the priority is to identify and eliminate the underlying cause of the autonomic dysreflexia. While medications may be needed if symptoms persist, treating the trigger (often bladder or bowel-related) is the most immediate and effective intervention. Giving medication without removing the stimulus does not resolve the root cause of the crisis.

B. Placing the client in a supine position is incorrect because it can worsen hypertension by increasing venous return and intracranial pressure. The recommended position is to elevate the head of the bed to reduce blood pressure and promote orthostatic pooling of blood in the lower extremities. Positioning alone, however, is not sufficient without addressing the triggering stimulus.

C. Checking the urinary catheter for kinks is the priority action because bladder distention is the most common cause of autonomic dysreflexia. An obstructed catheter can lead to rapid bladder filling, triggering the autonomic response. Immediate assessment and relief of urinary retention help reduce blood pressure and resolve symptoms quickly.

D. Performing digital rectal stimulation is contraindicated as an initial intervention because it may worsen the episode if a bowel impaction is present and has not been properly prepared for disimpaction. Additionally, rectal stimulation can further increase autonomic stimulation and elevate blood pressure. It should only be done after stabilizing the client and addressing more urgent causes such as bladder obstruction.

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Free Nursing Study Resources

Correct Answer is ["B","E","F"]

Explanation

Correct placement of an endotracheal tube after intubation is critical to ensure effective ventilation and prevent complications such as esophageal intubation or right mainstem bronchus placement. Verification requires a combination of clinical assessment and objective confirmation. Relying on a single method is unsafe, so multiple validation techniques are used to ensure accurate airway placement and adequate oxygenation.

Rationale:
A. Verifying the color of the tube is not a reliable method to confirm endotracheal tube placement. Tube color does not change based on anatomical position and provides no information about whether the tube is in the trachea or esophagus. This method is not used in clinical practice for confirmation of airway placement.

B. Observing symmetrical chest expansion helps assess whether both lungs are being ventilated. Unequal or absent chest movement may suggest endobronchial intubation or esophageal placement. While helpful, it must be used alongside other objective confirmation methods for accuracy.

C. Administering a dose of oxygen is not a verification method for tube placement. While oxygen delivery is essential after intubation, it does not confirm whether the tube is correctly positioned in the trachea. Oxygen administration is supportive care, not a diagnostic confirmation technique.

D. Measuring the external length of the tube from the lips is a method used to monitor for dislodgement or movement after the initial position has already been confirmed. While it helps ensure the tube stays in the same place (e.g., "22 cm at the teeth"), it cannot prove that the initial placement was in the trachea rather than the esophagus.

E. Auscultating for breath sounds bilaterally is a key method for verifying correct placement. Equal breath sounds over both lung fields suggest tracheal placement, while absent or unequal sounds may indicate esophageal or bronchial intubation. This method should always be combined with additional confirmation techniques.

F. Checking end-tidal carbon dioxide (EtCO₂) levels is the most reliable method for confirming tracheal placement. Presence of sustained CO₂ indicates that the tube is in the airway and that ventilation is occurring. This capnography confirmation is considered the gold standard for verifying correct endotracheal tube placement.

A. Acquired by coming into contact with infected blood or body fluids B. Passed on by casual contact, such as handshakes C. Spread through contaminated food or water D. Transmitted through respiratory droplets

Correct Answer is A

Explanation

Hepatitis B is a viral infection that primarily affects the liver and can lead to both acute and chronic liver disease. It is caused by the hepatitis B virus (HBV), which is highly infectious and can survive outside the body for several days. Transmission occurs when infected blood or certain body fluids enter another person’s bloodstream through percutaneous or mucosal exposure. Understanding the correct mode of transmission is essential for implementing appropriate infection control and prevention strategies.

Rationale:
A. Acquired by coming into contact with infected blood or body fluids is correct because hepatitis B is transmitted through exposure to infected blood, semen, vaginal secretions, and other body fluids. This can occur via needlestick injuries, unprotected sexual contact, sharing of needles, or from mother to child during childbirth. The virus is not spread through casual contact but requires direct exposure to infectious fluids.

B. Passed on by casual contact, such as handshakes, is incorrect because hepatitis B is not transmitted through everyday social interactions. Activities like shaking hands, hugging, coughing, or sharing utensils do not pose a risk of infection. The virus requires direct entry into the bloodstream or mucous membranes to cause infection.

C. Spread through contaminated food or water is incorrect because hepatitis B is not a fecal-oral transmitted virus. This mode of transmission is associated with hepatitis A and hepatitis E, which are spread through ingestion of contaminated substances. Hepatitis B specifically requires blood or body fluid exposure.

D. Transmitted through respiratory droplets is incorrect because hepatitis B does not spread via coughing, sneezing, or airborne particles. Respiratory droplet transmission is characteristic of infections like influenza or tuberculosis. HBV transmission is strictly related to blood and certain body fluid exposure rather than respiratory routes.

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A nurse is caring for a client with a C4 spinal cord injury with an indwelling urinary catheter who exhibits signs of autonomic dysreflexia, including a severe headache and hypertension. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following methods can be used to verify the correct placement of an endotracheal tube after intubation? Select All that Apply.

Correct Answer is ["B","E","F"]

Explanation

Which of the following modes of transmission is most associated with hepatitis B for a client who has been diagnosed with the virus?

Correct Answer is A

Explanation

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