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.

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Correct Answer is D

Explanation

Choice A rationale: Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.

Choice B rationale: While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.

Choice C rationale: Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.

Choice D rationale: Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.

A. Prepare the client for emergency surgery. B. Send a specimen for culture and sensitivity. C. Clamp the catheter and call the provider. D. Irrigate the peritoneal catheter with sterile saline

Correct Answer is B

Explanation

Choice A rationale: Cloudy efluent doesn't necessarily indicate a need for emergency surgery unless accompanied by severe symptoms.

Choice B rationale: Cloudy efluent may indicate infection, so obtaining a culture and sensitivity test is crucial for appropriate treatment.

Choice C rationale: This step might be necessary if the efluent suggests infection, but sending a specimen for testing is the immediate priority.

Choice D rationale: This action isn't the first step; investigating the cause of cloudiness through testing is essential.

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

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Naxlex Comprehensive Predictor Exams

A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?

Correct Answer is D

Explanation

When providing care for a client receiving peritoneal dialysis. While draining the dialysate the nurse notices that the efluent is cloudy. Which intervention is most important for the nurse to carry out at this moment?

Correct Answer is B

Explanation

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