Certified Gastroenterology RN Exam Prep

Category - Reduction of Risk

A nurse develops a plan of care for a client at risk for autonomic dysreflexia. Which of the following nursing actions is not included in the care plan?

  1. Administer pain medications as ordered
  2. Straight catheterization every 8 hours
  3. Adherence to bowel retraining program
  4. Keeping the client's linen wrinkle-free
Explanation

Answer - B - Autonomic dysreflexia is stimulated by a distended bladder, an impacted rectum, wrinkled linen, pain or another cause. Straight catheterization is done every 4 to 6 hours to prevent bladder distension. The other actions are appropriate.

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