The nurse assesses the client to determine the cause of autonomic dysreflexi().
A. Which of the following is the most common stimulus for an autonomic dysreflexia episodeA. Rising intracranial pressure.
Bowel distention.
C. Bladder distention.
D. Anxiety.
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The nurse observes that the client’s total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. What should the nurse do next
Assess the infusion system, note the client’s condition, and notify the physician.
B. Discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved.
C. Increase the flow rate to infuse an additional 300 mL over the next hour.
D. Maintain the flow rate at the current rate and document any discrepancy in the chart.
A client in labor received an epidural anesthetic when her dilation reached 5 cm. Which of the following nursing diagnoses would have the highest priority for her at this time
A. Impaired skin integrity related to inability to move lower extremities.
B. Impaired urinary elimination related to the effects of the epidural.
C. Deficient knowledge related to lack of information about regional anesthesia.
D. Risk for injury related to hypotension secondary to vasodilation and pooling in extremities.
Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy
A. Having the client take rapid, shallow breaths to decrease pain.
B. Having the client lay on the left side while coughing and deep breathing.
C. Teaching the client to use a folded blanket or pillow to splint the incision.
D. Withholding pain medication so the client can be alert enough to follow the nurse’s instructions.
Which of the following is an early symptom of glaucoma
A. Hazy vision.
B. Loss of central vision.
C. Blurred or "sooty" vision.
D. Impaired peripheral vision.
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