Latest Version | 2025/2026 | Correct &
Verified
1. A nurse is assessing a client who has a head injury following a motor-ve-
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hicle crash.The nurse should identify that which of the following findings
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indicates increasing intracranial pressure?
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a. restlessness
b. dizziness
c. hypotension
d. fever
Ans : a X5 X5
2. A nurse is planning care for a client following a lumbar puncture.Which of the
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following actions should the nurse plan to include?
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a. apply a pressure dressing to the site for 8 hr
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b. restrict the client's fluid intake for 24 hr
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c. ensure that the client lies flat for up to 12 hr
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d. inform the client that neck stiffness is an expected outcome of the proce-
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, X5 dure
Ans: c X5
3. A nurse is teaching an assistive personnel about care of a client who has
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had a total hip arthroplasty.Which of the following instructions should the
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nurse include?
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a. avoid applying antiembolism stockings to the affected leg
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b. have the client lean forward when moving from a sitting to a standing
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position
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c. discourage the client from sitting in a wheelchair with the back reclined X5 X5 X5 X5 X5 X5 X5 X5 X5 X5 X5
d. placeanabductorpillowbetweenthe client'slegs whenturning theclient
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Ans : d X5 X5
4. A nurse is planning care for a client who has a closed traumatic brain injury from
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a fall and is receiving mechanical ventilation.Which of the following
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interventions is the nurse's priority?
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a. maintain a PaCO2 of approx 35 mmHg X5 X5 X5 X5 X5 X5
b. provide small doses of fentanyl via IV bolus for pain management X5 X5 X5 X5 X5 X5 X5 X5 X5 X5
c. measure body temp every 1-2 hr X5 X5 X5 X5 X5
d. reposition the client every 2 hr X5 X5 X5 X5 X5
Ans: a X5
5. A nurse is teaching a client who has parkinson's disease about taking
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carbidopa-levodopa.Which of the following client statements indicates an
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understanding of the teaching?
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a. "I should expect an increase in my BP while taking this med"
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b. "I should take this med 2 hours after meals to increase absorption"
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c. "I should expect that this med can cause me to be drowsy"
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d. "I should expect this med to be effective within 48 hr"
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