with Accurate Answers 2026-2027
Updated Version.
A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and
diaphoretic. Which priority interventions should the nurse perform? Select all that apply.
1. Administer an analgesic as needed
2. Determine if there is bladder distention
3. Measure the client's blood pressure
4. Place the client in the Sims' position
5. Remove constrictive clothing - Answer 2, 3, 5
Determine if there is bladder distention
Measure the client's blood pressure
Remove constrictive clothing
The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding
constitutes an early sign of deterioration?
A. generalized pain
B. shortness of breath
C. tonic-clonic seizures
D. alteration in LOC - Answer D. Alteration in LOC
A patient admitted to the telemetry unit develops cardiac rhythm that is pulseless. What
medicine are you going to give first? - Answer Epinephrine
An ABG with an acute kidney injury had 4 sets of blood gases drawn. What set indicates partial
compensation by kidneys? - Answer partial compensation: nothing is normal
The parent of a 3 year old present to the ED reporting that the child turned over a hot pot of
soup on his face and chest. The nurse notes clothing is still in place and the child has redness
and swelling around the mouth and neck. Which action should the nurse take first?
,A. assess the child's airway for patency
B. initiate IV fluid resuscitation as ordered
C. administer IV pain medication as ordered
D. assess the severity of the face and chest burns - Answer A. assess the child's airway for
patency
When caring for the client with acute pancreatitis, which alterations does the nurse recognize is
consistent with the disease?
A. hypertension
B. hyperglycemia
C. polyuria
D. leukopenia - Answer B. hyperglycemia
Dobutamine (Dobutrex) is used to treat a client experiencing cardiogenic shock. Nursing
intervention includes:
A. monitoring for fluid overload
B. monitoring for cardiac dysrhythmias
C. monitoring respiratory status
D. monitoring for hypotension - Answer B. monitoring for cardiac dysrhythmias
A 32-year-old firefighter is brought to the emergency department after being trapped in a fire.
The firefighter is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is
exhibiting signs of acute respiratory distress syndrome (ARDS) and is intubated. What other
supportive measures are initiated in a patient with ARDS?
A. hemodynamic monitoring
B. nutritonal support
C. adequate oral intake
D. circulatory monitoring - Answer B. Nutritional Support
A client is admitted with septic shock. Which of the following data on day 2 would indicate the
client is improving?
(3 answers) - Answer Lactic Acid
, Urinary Output
Temperature
A client is admitted to intensive care unit with metabolic acidosis and an acute kidney injury.
What do you need to monitor? - Answer Cardiac Monitoring
The nurse is administering TPA (alteplase) to a new stroke patient that weighs 248 lbs. What is
the total dose the nurse should administer to this patient (0.9mg/kg) - Answer 248/2.2 =
112.73
0.9mg x 112.73kg = 101.5mg
The nurse is assisting a patient with right sided hemiparesis and dysphasia with eating. What do
you want to ensure for the patient? - Answer Swallowing, chewing, pocketing
Caring for a patient with a seizure disorder might include what? - Answer Documenting time
and details of seizure activity, teaching family and patient about safety, triggers, and risk factors
A priority nursing intervention in caring for a client who is having a seizure includes what?
A. elevate the HOB to 45 degrees
B. put the client in restraints
C. maintain airway
D. pad the side rails of the bed - Answer C. maintain the airways
The nurse caring for a client who is post status epilepticus is aware that status epilepticus can be
caused by which conditions? Select all that apply
A. anaphylactic reaction to medication
B. abrupt withdrawal of anticonvulsant medications
C. myocardial infarction
D. acute drug withdrawal
E. head trauma - Answer B. abrupt withdrawal of anticonvulsant medications
D. acute drug withdrawal
E. head trauma