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Questions 148

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Extract:


Question 1 of 5

The nurse recognizes all of the following as part of the Cushing reflex triad EXCEPT

Correct Answer: A

Rationale: Cushing reflex (response to increased intracranial pressure) includes hypertension, bradycardia, and irregular respirations. Cardiac arrhythmia is not part of the triad.

Question 2 of 5

The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?

Correct Answer: C

Rationale: Turning the client to one side prevents aspiration, a risk in CVA patients with nausea due to impaired swallowing or consciousness. This is the priority before other actions.

Question 3 of 5

The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows antithrombolic stockings should be applied:

Correct Answer: A

Rationale: Applying antithrombic stockings before rising prevents venous pooling, maximizing their effectiveness in improving circulation.

Question 4 of 5

A client comes into the emergency room after a chemical splashed into her eye at work. The priority nursing intervention is to

Correct Answer: C

Rationale: Immediate irrigation with saline removes the chemical, preventing further eye damage. Other actions follow after irrigation.

Question 5 of 5

The oncoming nurse receives report on a group of clients. Which client should have priority during the nurse's rounds?

Correct Answer: A

Rationale: A client just returning from surgery requires immediate assessment for postoperative complications, making them the priority.

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