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Question 1 of 5

The nurse should carefully monitor the client for which common dysrhythmia that can occur during suctioning?

Correct Answer: A

Rationale: Suctioning can stimulate the vagus nerve, leading to bradycardia due to parasympathetic activation, especially in clients with tracheostomies or endotracheal tubes.

Question 2 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 3 of 5

The nurse is reviewing labs on a group of adult clients. Which lab value would prompt the nurse to immediately notify the health care provider?

Correct Answer: A

Rationale: Hemoglobin of 4.8 g/dL is critically low, indicating severe anemia and requiring immediate provider notification. Other values are normal or near-normal.

Question 4 of 5

The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:

Correct Answer: A

Rationale: Prone positioning helps stretch hip flexors, preventing contractures after AKA by maintaining proper alignment.

Question 5 of 5

The nurse is caring for a client with an endemic goiter. The nurse recognizes that the client's condition is related to:

Correct Answer: A

Rationale: Endemic goiter is caused by iodine deficiency, often due to low iodine levels in soil, leading to inadequate thyroid hormone production.

Similar Questions

A client who is to undergo electroconvulsive therapy for severe depression is quite anxious about the treatment and asks the nurse what to expect after treatment. Which of the following information should the nurse include? Select all that apply.
The physician has prescribed imipramine (ToFranil) for a client with depression. The nurse should continue to monitor the client's affect because the maximal effects of tricyclic antidepressant medication do not occur for:
The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis?
A child with Down syndrome has a developmental age of 4 years. According to the Denver Developmental Assessment, the 4-year-old should be able to:
The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose?

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