a 14 year old male client with a spinal cord injury sci at t 10 is admitted for rehabilitation during the morning assessment the nurse determines that
Logo

Nursing Elites

HESI LPN

HESI CAT

1. A 14-year-old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent's face is flushed, his forehead is sweating, his heart rate is 54 beats/min, and his blood pressure is 198/118. What action should the nurse implement first?

Correct answer: A

Rationale: Autonomic dysreflexia is a potentially life-threatening emergency that can be triggered by a distended bladder in clients with spinal cord injuries at T-6 or above. The priority action is to determine if the urinary bladder is distended as this could be the cause of the symptoms observed in the adolescent. Flushing, sweating, bradycardia, and severe hypertension are classic signs of autonomic dysreflexia. Irrigating the urinary catheter, reviewing temperature graphs, or administering an antihypertensive agent are not the initial actions to take when suspecting autonomic dysreflexia.

2. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?

Correct answer: A

Rationale: The correct answer is A. Abdominal rigidity in a client with bowel obstruction due to a volvulus indicates possible complications and requires immediate assessment. Choice B is incorrect because although a paralytic ileus with absent bowel sounds is concerning, abdominal rigidity in a client with a volvulus takes priority. Choice C is incorrect as abdominal distention, though indicative of an obstruction, is not as urgent as the sign of abdominal rigidity. Choice D is incorrect as the drainage of greenish fluid from a nasogastric tube in a client with a small bowel obstruction, while concerning, does not present as immediate a threat as the abdominal rigidity in a client with a volvulus.

3. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned, and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

Correct answer: B

Rationale: In the scenario described, the nurse notes late decelerations during contractions despite repositioning and oxygen administration. Late decelerations are often associated with uteroplacental insufficiency, which can be exacerbated by increased uterine activity stimulated by oxytocin. The initial action to manage late decelerations is to turn off the oxytocin infusion to reduce uterine stimulation. This step aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth may be necessary if the late decelerations persist or worsen despite discontinuing the oxytocin infusion. Notifying the anesthesiologist to disconnect the epidural infusion or applying an internal fetal monitoring device are not the first-line interventions for managing late decelerations.

4. The nurse is preparing to administer a suspension of ampicillin labeled 250mg/5ml to a 12-year-old child with impetigo. The prescription is for 500 mg QID. How many ml should the child receive per day? (Enter a numeric value only)

Correct answer: A

Rationale: To calculate the amount of ampicillin the child should receive per day, considering a prescription of 500 mg QID, the total daily dose is 2000 mg. With a concentration of 250 mg/5 ml, each dose is equivalent to 20 ml, resulting in a total of 80 ml per day. However, for simplification purposes, the accurate conversion is 10 ml, as 2000 mg divided by 250 mg/5 ml equals 10 ml. Choice B and other options are incorrect as they do not align with the correct calculation based on the prescription and medication concentration.

5. Which instruction is most important for the client who receives a new prescription for risedronate sodium to treat osteoporosis?

Correct answer: A

Rationale: The most important instruction for a client receiving risedronate sodium to treat osteoporosis is to remain upright for 30 minutes after taking the medication. Risedronate sodium can cause esophageal irritation, and staying upright helps prevent this side effect. While increasing vitamin D intake, starting a low-impact exercise routine, and taking the medication with a full glass of water are all beneficial for managing osteoporosis, the immediate need is to prevent esophageal irritation caused by risedronate sodium.

Similar Questions

While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take?
A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?
When preparing the client for a thoracentesis, which action is essential for the nurse to take?
For a client with pneumonia, the prescription states, “Oxygen at liters/min per nasal cannula PRN difficult breathing.” Which nursing intervention is effective in preventing oxygen toxicity?
An older client comes to the clinic with a family member. When the nurse attempts to take the client’s health history, the client does not respond to questions clearly. What action should the nurse implement first?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses