NCLEX Examination & Reviews And Nursing Test Prep

A client diagnosed with a C6 spinal cord injury and reporting a headache. (Correct Answer)

A severe headache is indicative of autonomic dysreflexia in the client who has sustained a high-level spinal cord injury. Autonomic dysreflexia is associated with a dangerously high blood pressure, and, if untreated, can result in intracranial bleeding and death. This client is the most unstable and is experiencing a potentially life-threatening issue that needs to be addressed immediately by the nurse.

Client diagnosed with progressive systemic sclerosis and experiencing Raynaud phenomenon. (Correct Answer)

Progressive systemic sclerosis is a chronic connective tissue disease that causes inflammation, fibrosis, and sclerosis of the skin and vital organs. This is a stable client with predictable outcomes and who can be assigned the nurse with postpartum care experience.

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Time the medication administration with a watch. (Correct Answer)

Using a watch to time the administration ensures safe medication infusion. Ideally, the watch should have a second hand or digital readout. Many medications that are prescribed as IV push or bolus need to be given slowly over several minutes