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Question 1 of 5

According to the American Heart Association (2005) guidelines the compression-to-ventilation ratio for one rescuer cardiopulmonary resuscitation is:

Correct Answer: C

Rationale: The 2005 AHA guidelines specify a 30:2 compression-to-ventilation ratio for one-rescuer CPR in adults.

Question 2 of 5

A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?

Correct Answer: A

Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.

Question 3 of 5

A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:

Correct Answer: B

Rationale: Pancreatic enzymes are taken with meals to aid digestion, as cystic fibrosis impairs pancreatic enzyme production.

Question 4 of 5

The nurse is preparing to administer a dose of hydralazine (Apresoline) to a client with hypertension. The client’s blood pressure is 90/60 mmHg. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: hydralazine is a vasodilator, and a blood pressure of 90/60 mmHg indicates hypotension, so the dose should be withheld

Question 5 of 5

The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?

Correct Answer: D

Rationale: Respiratory stridor post-tonsillectomy indicates airway obstruction, a life-threatening complication requiring immediate reporting.

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The nurse recognizes all of the following as part of the Cushing reflex triad EXCEPT
A client has recently lost her best friend to cancer. The client tells the nurse, 'I'm very sad about the loss of my friend.' Which of the following responses by the nurse is the most appropriate?

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