hard · NCLEX-RN physiological
The nurse prepares to initiate immediate priority actions. Sequence the nurse's next steps in the correct order of clinical priority. Apply the response specifically to this case: T6 spinal cord injury with autonomic dysreflexia triggered by a blocked urinary catheter, severe hypertension, reflex bradycardia, and recurrent-trigger prevention.
- Elevate the head of the bed to 90 degrees (high-Fowler's position).
- Loosen the client's gown, abdominal binder, and any other tight clothing.
- Inspect the indwelling urinary catheter tubing for kinks, twists, or obstructions.
- Perform a gentle irrigation of the catheter with 10 mL of sterile normal saline.
- Apply topical nitroglycerin 2% ointment as ordered if systolic blood pressure remains above 150 mm Hg after bladder decompression.
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