the nurse is caring for a client with a spinal cord injury which intervention should the nurse implement to prevent autonomic dysreflexia
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Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. The nurse is caring for a client with a spinal cord injury. Which intervention should the nurse implement to prevent autonomic dysreflexia?

Correct answer: C

Rationale: To prevent autonomic dysreflexia in clients with spinal cord injuries, it is crucial to ensure the client's bladder is emptied regularly. Bladder distention is a common trigger for autonomic dysreflexia in these clients. Keeping the bladder empty helps prevent the complications associated with autonomic dysreflexia, such as dangerously high blood pressure. Choices A, B, and D are incorrect. Restricting fluid intake can lead to dehydration, keeping the room warm is not directly related to preventing autonomic dysreflexia, and limiting high-fiber foods is not a primary intervention for this condition.

2. A 70-year-old man presents with weight loss, jaundice, and a palpable mass in the right upper quadrant. Laboratory tests reveal elevated bilirubin and alkaline phosphatase levels. What is the most likely diagnosis?

Correct answer: C

Rationale: The presentation of a 70-year-old man with weight loss, jaundice, a palpable mass in the right upper quadrant, and elevated bilirubin and alkaline phosphatase levels is highly suggestive of pancreatic cancer. This clinical scenario, known as Courvoisier's sign, points towards a pancreatic malignancy due to biliary obstruction. Gallstones could cause similar symptoms but would typically not present with a palpable mass. Hepatitis usually does not present with a palpable mass and would have different laboratory findings. Primary biliary cirrhosis typically presents differently with chronic cholestasis without the presence of a palpable mass or a pancreatic lesion.

3. When assessing a client with a chest tube connected to suction, which observation indicates that the chest tube is functioning properly?

Correct answer: D

Rationale: Steady bubbling in the suction control chamber is the correct observation that indicates the chest tube is functioning properly. This steady bubbling signifies that the suction is actively maintaining the desired pressure level within the system, ensuring proper drainage and lung re-expansion. Continuous bubbling in the water seal chamber, intermittent bubbling in the suction control chamber, or no fluctuation in the water seal chamber are not indicative of optimal chest tube function and may require further assessment or intervention.

4. A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for the treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time?

Correct answer: B

Rationale: The best action for the nurse to take in this situation is to help the client directly contact the HMO to seek information about limitations of coverage. This approach addresses the client's immediate concerns and clarifies the situation, enabling the client to understand the coverage and potential outcomes regarding the bone marrow transplant. Choice A is not the best option as having the healthcare provider write a letter may not provide immediate clarification on coverage. Choice C is inappropriate as legal action should be considered as a last resort, and choice D involving the state board of insurance is not necessary at this initial stage of addressing the client's concern.

5. The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

Correct answer: B

Rationale: Prothrombin time (PT) is monitored to ensure therapeutic levels of warfarin and prevent bleeding complications.

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