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A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?
- A. The client's bladder becomes distended.
- B. The client states having a severe headache.
- C. The client states having nasal congestion.
- D. The client's blood pressure becomes elevated.
Correct Answer: A
Rationale: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure.
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A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Heparin is available in a concentration of 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 24
Rationale: Calculation: (1,200 units/hr ÷ 25,000 units) × 500 mL = 24 mL/hr
A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease (CKD). Which of the following findings should the nurse expect?
- A. BUN 8 mg/dL and creatinine 0.7 mg/dL
- B. BUN 45 mg/dL and creatinine 8 mg/dL
- C. BUN 10 mg/dL and creatinine 0.3 mg/dL
- D. BUN 23 mg/dL and creatinine 1.0 mg/dL
Correct Answer: B
Rationale: Elevated BUN and creatinine reflect impaired kidney function in CKD.
A nurse is caring for a client who had a stroke and has dysphagia. For which of the following complications should the nurse monitor the client?
- A. Aspiration
- B. Gastroesophageal reflux disease
- C. Peptic ulcer disease
- D. Dumping syndrome
Correct Answer: A
Rationale: Aspiration is the primary concern with dysphagia due to impaired swallowing reflexes.
The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?
- A. Frequent nosebleeds and bruising
- B. Urinary retention
- C. No bowel movement in three days
- D. Increased blood glucose
Correct Answer: A
Rationale: Coagulopathy (evidenced by bleeding) is serious in cirrhosis due to impaired clotting factor production.
A nurse is teaching a client who has acute kidney injury (AKI) about the oliguric phase. Which of the following information should the nurse include in the teaching?
- A. The glomerular filtration rate (GFR) recovers.
- B. Urine output is less than 400 mL per 24 hours.
- C. BUN and creatinine levels decrease.
- D. Renal function is reestablished.
Correct Answer: B
Rationale: Oliguria (<400mL/24hr) defines this phase of AKI with impaired urine production.