The nurse is caring for a client with Cushing's triad. The nurse expects the client to have:

Irregular respirations, bradycardia, and widening pressure

Hypotension, jugular venous distention, and mufled heart sound

Fixed pupils, hypertension, and bradycardia

Bradycardia, hypotension, and bradypnea

Answer and Explanation

The Correct Answer is C

Choice A rationale: Irregular respirations, bradycardia, and widened pulse pressure might indicate increased intracranial pressure.

Choice B rationale: This set of symptoms is often seen in cardiac tamponade and is referred to as the Beck’s triad and not Cushing's triad.

Choice C rationale: Cushing's triad is a set of clinical signs associated with increased intracranial pressure (ICP) and typically includes bradycardia (slow heart rate),

hypertension (elevated blood pressure), and irregular breathing patterns. Fixed pupils can also be present in some cases, but it's important to note that this triad is not always consistently present and may vary from person to person.

Choice D rationale: This set of symptoms describes symptoms of shock, not specifically Cushing's triad.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale: The correct answer is 5 units/hour. To calculate the units of insulin per hour, we need to use the following formula: units of insulin per hour = (units of insulin in the bag / volume of the bag) x infusion rate

Plugging in the given values, we get:

units of insulin per hour = (50 / 100) x 10 units of insulin per hour = 0.5 x 10

units of insulin per hour = 5

Therefore, the client is receiving 5 units of insulin every hour.

Choice B rationale: This is incorrect because it assumes that the infusion rate is equal to the units of insulin per hour, which is not true.

Choice C rationale: This is incorrect because it multiplies the units of insulin in the bag by the infusion rate, which is too high.

Choice D rationale: This is incorrect because it adds the units of insulin in the bag and the infusion rate, which is also too high.

A. The skin under the appliance looks red briefly after removing the appliance. B. The stoma color is a deep red-purple. C. An ascending colostomy delivers liquid feces. D. The stoma extends 1/2 inch above the abdomen.

Correct Answer is B

Explanation

Choice A rationale: Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.

Choice B rationale: A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.

Choice C rationale: The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.

Choice D rationale: The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client with Cushing's triad. The nurse expects the client to have:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving 10 mL/hr of a prescribed regular insulin infusion. The label on the bag reads 50 units of regular insulin in 100 mL of 0.9% saline. How many units of insulin is the client receiving every hour? Fill in the blank. Round your answer to the nearest whole number.

Correct Answer is A

Explanation

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

Correct Answer is B

Explanation

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

The nurse is caring for a 67-year-old client in the medical-surgical unit following hemodialysis. The nurse reviews the nursing note, vital signs, assessment, and medical history Which clinical data is most concerning to the nurse? Select all that apply

A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

The nurse is teaching a client with Parkinson's disease about dietary considerations. The nurse understands that this client is at highest risk for:

Upon physical examination, the nurse detects abdominal tenderness, increased bowel sounds accompanied by signs of borborygmi, abdominal distension, and tympany on percussion. Which diagnostic test will confirm Crohn's disease in the client?

Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication-related side effects?

The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?