When the nurse observes a patient experiencing a severe episode of autonomic dysreflexia, what should be the initial intervention?
a. Locate the cause of irritation
b. Assess the blood pressure
c. Cover the patient with several blankets
d. Raise the head of the bed to a high Fowler position
ANS: D
The head of the bed should be raised immediately. Raising the head of the bed will reduce the blood pressure. Finding the cause of the episode is secondary to preventing the possibility of a stroke from the hypertension.
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IV fluid 250 mL was to be infused in 3 hours using 20 gtt/mL tubing. With 1 1/2 hours remaining, you find 200 mL left. Recalculate the flow rate in gtt/min. _____
a. 13 b. 17 c. 44 d. 33
A patient with heart failure asks you why the antihypertensive drug enalapril (Vasotec) has been prescribed. What is your best response?
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A child has been struck by a car and has perfuse bleeding from the left leg. The nurse at the scene is assessing the patient. Identify the signs and symptoms the patient will have if hypovolemic shock is occurring. Select all that apply
1. Sweating 2. Ruddy skin 3. Bounding pulses in the lower extremities 4. A rapid respiratory rate 5. A rapid heart rate