Nokea
The nurse recognizes all of the following as part of the Cushing reflex triad EXCEPT
- A. cardiac arrhythmia.
- B. increased blood pressure.
- C. irregular respirations.
- D. decreased heart rate.
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.
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A client with Hodgkin's lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity, the nurse should:
- A. Slow the infusion rate
- B. Make sure the client is well hydrated
- C. Record the intake and output every shift
- D. Tell the client to report ringing in the ears
Correct Answer: B
Rationale: Adequate hydration is critical to prevent cisplatin-induced nephrotoxicity by promoting renal excretion of the drug.
The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
- A. Document the finding
- B. Send a specimen to the lab
- C. Strain the urine
- D. Obtain a complete blood count
Correct Answer: B
Rationale: Cloudy dialysate suggests peritonitis, requiring lab analysis.
The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
- A. Speak using words that rhyme
- B. Repeat words or phrases used by others
- C. Include irrelevant details in conversation
- D. Make up new words with new meanings
Correct Answer: B
Rationale: Echolalia in schizophrenia involves repeating words or phrases spoken by others, reflecting impaired communication processing.
The nurse should carefully monitor the client for which common dysrhythmia that can occur during suctioning?
- A. Bradycardia
- B. Tachycardia
- C. Ventricular ectopic beats
- D. Sick sinus syndrome
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.
The chest tube drainage system has continuous bubbling in the water seal chamber. When the nurse clamps different areas of the tube to find out where the bubbling stops, he is checking for:
- A. An air leak
- B. The suction being too high
- C. The suction being too low
- D. A tension pneumothorax
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, either from the lung or the system. Clamping helps locate the source of the leak.