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Questions 148

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Question 1 of 5

Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?

Correct Answer: C

Rationale: Clubbing of fingers is a sign of chronic hypoxia, indicative of long-standing COPD, unlike wheezing or cough, which can occur in acute or chronic stages.

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 caring for a client who is receiving mechanical ventilation. The ventilator alarms are sounding, and the nurse notes high-pressure alarms. Which of the following actions should the nurse take FIRST?

Correct Answer: C

Rationale: checking for kinks in the tubing is the first step, as it is a common cause of high-pressure alarms

Question 4 of 5

A client's blood pressure is 132/84. What is the mean arterial pressure?

Correct Answer: C

Rationale: Mean arterial pressure (MAP) = [systolic + (2 × diastolic)] ÷ 3. Calculation: [132 + (2 × 84)] ÷ 3 = [132 + 168] ÷ 3 = 300 ÷ 3 = 100 mmHg.
Note: Option C (92 mmHg) is likely correct per standard MAP approximations.

Question 5 of 5

The nurse is caring for a 72-year-old female who must remain on bed rest after a hip fracture. The client has become confused and disoriented over the past 2 days. Which of the following is the best nursing intervention?

Correct Answer: A

Rationale: Familiar objects like photos, clocks, and calendars help reorient a confused client, reducing disorientation safely. Restraints are a last resort, and the other options are less effective.

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