ICU practice NCLEX Exam Questions With Complete
Solutions
A client admitted to the hospital for repair of an unruptured
cerebral aneurysm. Before surgery, the nurse performs frequent
assessments on the client. Which assessment finding would be
noted first if the aneurysm ruptures?
A. Widened pulse pressure
B. Unilateral motor weakness
C. Unilateral slowing of pupil response
D. A decline in the level of consciousness Correct Answer
Answer Key: D
Feedback: Good Job! Rupture of a cerebral aneurysm usually
results in increased intracranial pressure (ICP). The first sign of
increased pressure in the brain is a change in the level of
consciousness. This change in consciousness can be as subtle as
drowsiness or restlessness. Because centers that control blood
pressure are located lower in the brain than those that control
consciousness, pulse pressure alteration is a later sign. Slowing
of pupil response and motor weakness are also late signs.
A client begins to experience a tonic clonic seizure. The nurse
should take which of the following actions? Select all that apply.
A. Restrain the client
B. Turn the client to the side
C. Maintain the client's airway
D. Place a padded tongue blade into the client's mouth
,E. Loosen any restrictive clothing that the client is wearing
F. Protect the client from injury and guide the client's
movements Correct Answer Answer Key: B, C, E, F
Feedback: Good Job! Precautions are taken to prevent a client
from sustaining injury during a seizure. The nurse would
maintain the client's airway and turn the client to the side. The
nurse would also protect the client from injury, guide the client's
movements, and loosen any clothing. Restraints are never used
because they could injure the client during the seizure. A padded
tongue blade or any other object is never placed into the client's
mouth after a seizure begins because the jaw may clench down.
A client has an arteriovenous (AV) fistula in place in the right
upper extremity for hemodialysis treatments. When planning
care for this client, which of the following measures should the
nurse implement to promote client safety.
A. Take blood pressures only on the right arm to ensure
accuracy
B. Use the fistula for all venipunctures and intravenous
infusions
C. Ensure that small clamps are attached to the AV fistula
dressing
D. Assess the fistula for the presence of a bruit and thrill every
4 hours Correct Answer Answer Key: D
, Feedback: Fistulas should be evaluated for the presence of a
thrills (palpate over the area) and bruits (auscultate with a
stethoscope) as an assessment of patency.
A client in renal failure is at risk for hyperkalemia. The nurse
monitors for which of the following clinical manifestations of
hyperkalemia?
A. Tall peaked T waves
B. Flattened P waves
C. Prominent U wave on EKG
D. Widened QRS Correct Answer Answer Key: A, B, D
Feedback: Tall peaked T waves, flattened P waves, and widened
QRS are signs and symptoms of hyperkalemia. U waves are
present in hypokalemia.
A client involved in a house fire is experiencing respiratory
distress, and an inhalation injury is suspected. The nurse
monitors which of the following for the presence of carbon
monoxide poisoning?
A. Pulse oximetry
B. Urine myoglobin
C. Sputum carbon levels
D. Serum carboxyhemoglobin levels Correct Answer Answer
Key: D
Feedback: Good Job! Serum carboxyhemoglobin levels are the
most direct measure of carbon monoxide poisoning, provide the
Solutions
A client admitted to the hospital for repair of an unruptured
cerebral aneurysm. Before surgery, the nurse performs frequent
assessments on the client. Which assessment finding would be
noted first if the aneurysm ruptures?
A. Widened pulse pressure
B. Unilateral motor weakness
C. Unilateral slowing of pupil response
D. A decline in the level of consciousness Correct Answer
Answer Key: D
Feedback: Good Job! Rupture of a cerebral aneurysm usually
results in increased intracranial pressure (ICP). The first sign of
increased pressure in the brain is a change in the level of
consciousness. This change in consciousness can be as subtle as
drowsiness or restlessness. Because centers that control blood
pressure are located lower in the brain than those that control
consciousness, pulse pressure alteration is a later sign. Slowing
of pupil response and motor weakness are also late signs.
A client begins to experience a tonic clonic seizure. The nurse
should take which of the following actions? Select all that apply.
A. Restrain the client
B. Turn the client to the side
C. Maintain the client's airway
D. Place a padded tongue blade into the client's mouth
,E. Loosen any restrictive clothing that the client is wearing
F. Protect the client from injury and guide the client's
movements Correct Answer Answer Key: B, C, E, F
Feedback: Good Job! Precautions are taken to prevent a client
from sustaining injury during a seizure. The nurse would
maintain the client's airway and turn the client to the side. The
nurse would also protect the client from injury, guide the client's
movements, and loosen any clothing. Restraints are never used
because they could injure the client during the seizure. A padded
tongue blade or any other object is never placed into the client's
mouth after a seizure begins because the jaw may clench down.
A client has an arteriovenous (AV) fistula in place in the right
upper extremity for hemodialysis treatments. When planning
care for this client, which of the following measures should the
nurse implement to promote client safety.
A. Take blood pressures only on the right arm to ensure
accuracy
B. Use the fistula for all venipunctures and intravenous
infusions
C. Ensure that small clamps are attached to the AV fistula
dressing
D. Assess the fistula for the presence of a bruit and thrill every
4 hours Correct Answer Answer Key: D
, Feedback: Fistulas should be evaluated for the presence of a
thrills (palpate over the area) and bruits (auscultate with a
stethoscope) as an assessment of patency.
A client in renal failure is at risk for hyperkalemia. The nurse
monitors for which of the following clinical manifestations of
hyperkalemia?
A. Tall peaked T waves
B. Flattened P waves
C. Prominent U wave on EKG
D. Widened QRS Correct Answer Answer Key: A, B, D
Feedback: Tall peaked T waves, flattened P waves, and widened
QRS are signs and symptoms of hyperkalemia. U waves are
present in hypokalemia.
A client involved in a house fire is experiencing respiratory
distress, and an inhalation injury is suspected. The nurse
monitors which of the following for the presence of carbon
monoxide poisoning?
A. Pulse oximetry
B. Urine myoglobin
C. Sputum carbon levels
D. Serum carboxyhemoglobin levels Correct Answer Answer
Key: D
Feedback: Good Job! Serum carboxyhemoglobin levels are the
most direct measure of carbon monoxide poisoning, provide the
