NUR 221 EXAM 4 | 358 ACTUAL QUESTIONS
AND CORRECT DETAILED ANSWERS |
ALREADY SCORED A+ | NEW UPDATE 2025
The nurse admits a patient to the critical care unit following a motorcycle crash.
Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart
rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5° F.
The patient is lethargic, responds to voice but falls asleep readily when not
stimulated. Which nursing action is most important to include in this patient's
plan of care?
A. Frequent neurological assessments
B. Side to side position changes
C. Range of motion to extremities
D. Frequent oropharyngeal suctioning - ANSWER A. Frequent neurological
assessments
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.; blood
pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What
is the cerebral perfusion pressure (CPP)?
A. 54 mm Hg
B. 72 mm Hg
C. 90 mm Hg
D. 126 mm Hg - ANSWER C. 90 mm Hg
,CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg.
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP
of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the
nurse?
A. Both pressures are high.
B. Both pressures are low.
C. ICP is high; CPP is normal.
D. ICP is high; CPP is low. - ANSWER C. ICP is high; CPP is normal.
The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18
mm Hg. The nurse needs to perform an hourly neurological assessment, suction
the endotracheal tube, perform oral hygiene care, and reposition the patient to
the left side. What is the best action by the nurse?
A. Hyperoxygenate during endotracheal suctioning.
B. Elevate the patient's head of the bed 30 degrees.
C. Apply bilateral heel protectors after repositioning.
D. Provide rest periods between nursing interventions. - ANSWER D. Provide
rest periods between nursing interventions.
While caring for a patient with a basilar skull fracture, the nurse assesses clear
drainage from the patient's left naris. What is the best nursing action?
,A. Have the patient blow the nose until clear.
B. Insert bilateral cotton nasal packing.
C. Place a nasal drip pad under the nose.
D. Suction the left nares until the drainage clears. - ANSWER C. Place a nasal
drip pad under the nose.
The nurse is caring for a patient who was hit on the head with a hammer. The
patient was unconscious at the scene briefly but is now conscious upon arrival at
the emergency department (ED) with a GCS score of 15. One hour later, the nurse
assesses a GCS score of 3. What is the priority nursing action?
A. Stimulate the patient hourly.
B. Continue to monitor the patient.
C. Elevate the head of the bed.
D. Notify the primary care provider immediately. - ANSWER D. Notify the
primary care provider immediately.
The nurse is caring for a patient with an intracranial pressure ICP of 18 mm Hg and
a GCS score of 3. Following the administration of mannitol, which assessment
finding by the nurse requires further action?
A. ICP of 10 mm Hg
B. CPP of 70 mm Hg
C. GCS score of 5
D. CVP of 2 mm Hg - ANSWER D. CVP of 2 mm Hg
, The nurse is caring for a mechanically ventilated patient with a brain injury.
Arterial blood gas values indicate a PaCO 2 of 60 mm Hg. The nurse understands
this value to have which effect on cerebral blood flow?
A. Altered cerebral spinal fluid production and reabsorption
B. Decreased cerebral blood volume due to vessel constriction
C. Increased cerebral blood volume due to vessel dilation
D. No effect on cerebral blood flow (PaCO 2 of 60 mm Hg is normal) - ANSWER
C. Increased cerebral blood volume due to vessel dilation
The nurse assesses a patient with a skull fracture and notes a Glasgow Coma Scale
score of 3. Additional vital signs assessed by the nurse include blood pressure
100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen
saturation (SpO 2 ) 94% on oxygen at 3 L per nasal cannula. What is the priority
nursing action?
A. Monitor the patient's airway patency.
B. Elevate the head of the patient's bed.
C. Increase supplemental oxygen delivery.
D. Support bony prominences with padding. - ANSWER A. Monitor the
patient's airway patency.
The nurse is caring for a patient admitted to the ED following a fall from a 10-foot
ladder. Upon admission, the nurse assesses the patient to be awake, alert, and
moving all four extremities. The nurse also notes bruising behind the left ear and
straw-colored drainage from the left nare. What is the most appropriate nursing
action?
AND CORRECT DETAILED ANSWERS |
ALREADY SCORED A+ | NEW UPDATE 2025
The nurse admits a patient to the critical care unit following a motorcycle crash.
Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart
rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5° F.
The patient is lethargic, responds to voice but falls asleep readily when not
stimulated. Which nursing action is most important to include in this patient's
plan of care?
A. Frequent neurological assessments
B. Side to side position changes
C. Range of motion to extremities
D. Frequent oropharyngeal suctioning - ANSWER A. Frequent neurological
assessments
A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.; blood
pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What
is the cerebral perfusion pressure (CPP)?
A. 54 mm Hg
B. 72 mm Hg
C. 90 mm Hg
D. 126 mm Hg - ANSWER C. 90 mm Hg
,CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg.
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP
of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the
nurse?
A. Both pressures are high.
B. Both pressures are low.
C. ICP is high; CPP is normal.
D. ICP is high; CPP is low. - ANSWER C. ICP is high; CPP is normal.
The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18
mm Hg. The nurse needs to perform an hourly neurological assessment, suction
the endotracheal tube, perform oral hygiene care, and reposition the patient to
the left side. What is the best action by the nurse?
A. Hyperoxygenate during endotracheal suctioning.
B. Elevate the patient's head of the bed 30 degrees.
C. Apply bilateral heel protectors after repositioning.
D. Provide rest periods between nursing interventions. - ANSWER D. Provide
rest periods between nursing interventions.
While caring for a patient with a basilar skull fracture, the nurse assesses clear
drainage from the patient's left naris. What is the best nursing action?
,A. Have the patient blow the nose until clear.
B. Insert bilateral cotton nasal packing.
C. Place a nasal drip pad under the nose.
D. Suction the left nares until the drainage clears. - ANSWER C. Place a nasal
drip pad under the nose.
The nurse is caring for a patient who was hit on the head with a hammer. The
patient was unconscious at the scene briefly but is now conscious upon arrival at
the emergency department (ED) with a GCS score of 15. One hour later, the nurse
assesses a GCS score of 3. What is the priority nursing action?
A. Stimulate the patient hourly.
B. Continue to monitor the patient.
C. Elevate the head of the bed.
D. Notify the primary care provider immediately. - ANSWER D. Notify the
primary care provider immediately.
The nurse is caring for a patient with an intracranial pressure ICP of 18 mm Hg and
a GCS score of 3. Following the administration of mannitol, which assessment
finding by the nurse requires further action?
A. ICP of 10 mm Hg
B. CPP of 70 mm Hg
C. GCS score of 5
D. CVP of 2 mm Hg - ANSWER D. CVP of 2 mm Hg
, The nurse is caring for a mechanically ventilated patient with a brain injury.
Arterial blood gas values indicate a PaCO 2 of 60 mm Hg. The nurse understands
this value to have which effect on cerebral blood flow?
A. Altered cerebral spinal fluid production and reabsorption
B. Decreased cerebral blood volume due to vessel constriction
C. Increased cerebral blood volume due to vessel dilation
D. No effect on cerebral blood flow (PaCO 2 of 60 mm Hg is normal) - ANSWER
C. Increased cerebral blood volume due to vessel dilation
The nurse assesses a patient with a skull fracture and notes a Glasgow Coma Scale
score of 3. Additional vital signs assessed by the nurse include blood pressure
100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen
saturation (SpO 2 ) 94% on oxygen at 3 L per nasal cannula. What is the priority
nursing action?
A. Monitor the patient's airway patency.
B. Elevate the head of the patient's bed.
C. Increase supplemental oxygen delivery.
D. Support bony prominences with padding. - ANSWER A. Monitor the
patient's airway patency.
The nurse is caring for a patient admitted to the ED following a fall from a 10-foot
ladder. Upon admission, the nurse assesses the patient to be awake, alert, and
moving all four extremities. The nurse also notes bruising behind the left ear and
straw-colored drainage from the left nare. What is the most appropriate nursing
action?
