Certified Gastroenterology RN Exam Prep

Category - Reduction of Risk

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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?

Administer pain medications as ordered
Straight catheterization every 8 hours
Adherence to bowel retraining program
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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