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U WORLD NCLEX-PN ACTUAL QUESTIONS
& ANSWERS WITH RATIONALES
(A+ GUIDE SOLUTION)
Terms in this set (20)
>> The nurse is caring for the client with increased intracranial pressure. The nurse would note
which trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, decreasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
- correct answer- 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing
blood pressure
A change in vital signs may be a late sign of increased intracranial pressure. Trends include
increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory
irregularities also may occur.
>> The nurse has established a goal to maintain intracranial pressure (ICP) within the normal
range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that
apply.
1. Encourage the client to cough to expectorate secretions.
2. Elevate the head of the bed 15 - 20 degrees.
3. Contact the HCP if ICP is >15 mmHg.
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4. Monitor neurologic status using the Glasgow Coma Scale.
5. Stimulate the client with active range-of-motion exercises.
- correct answer- 2, 3, 4
The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and monitoring
neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper limits of normal indicates
increased ICP, and the nurse should notify the HCP. Coughing and range of motion exercises will
increase ICP and should be avoided in the early postoperative stage.
>> What should the nurse do first when a client with a head injury begins to have clear
drainage from the nose?
1. Compress the nares
2. Tilt the head back
3. Collect the drainage
4. Administer an antihistamine for postnasal drip
- correct answer- 3
The clear drainage must be analyzed to determine whether it is nasal drainage or CSF. The nurse
should not give the client tissues because it is important to know how much leakage of CSF is
occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the
head back, which would allow the fluid to drain down the throat and not be collected for a
sample. It is inappropriate to administer an antihistamine because the drainage may not be
from postnasal drip.
>> A client has clear fluid leaking from the nose following a basilar skull fracture. Which
finding would alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly blood in appearance and has a pH of 6
3. Fluid clumps together on the dressing and had a pH of 7
U WORLD NCLEX-PN ACTUAL QUESTIONS
& ANSWERS WITH RATIONALES
(A+ GUIDE SOLUTION)
Terms in this set (20)
>> The nurse is caring for the client with increased intracranial pressure. The nurse would note
which trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, decreasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
- correct answer- 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing
blood pressure
A change in vital signs may be a late sign of increased intracranial pressure. Trends include
increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory
irregularities also may occur.
>> The nurse has established a goal to maintain intracranial pressure (ICP) within the normal
range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that
apply.
1. Encourage the client to cough to expectorate secretions.
2. Elevate the head of the bed 15 - 20 degrees.
3. Contact the HCP if ICP is >15 mmHg.
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4. Monitor neurologic status using the Glasgow Coma Scale.
5. Stimulate the client with active range-of-motion exercises.
- correct answer- 2, 3, 4
The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and monitoring
neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper limits of normal indicates
increased ICP, and the nurse should notify the HCP. Coughing and range of motion exercises will
increase ICP and should be avoided in the early postoperative stage.
>> What should the nurse do first when a client with a head injury begins to have clear
drainage from the nose?
1. Compress the nares
2. Tilt the head back
3. Collect the drainage
4. Administer an antihistamine for postnasal drip
- correct answer- 3
The clear drainage must be analyzed to determine whether it is nasal drainage or CSF. The nurse
should not give the client tissues because it is important to know how much leakage of CSF is
occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the
head back, which would allow the fluid to drain down the throat and not be collected for a
sample. It is inappropriate to administer an antihistamine because the drainage may not be
from postnasal drip.
>> A client has clear fluid leaking from the nose following a basilar skull fracture. Which
finding would alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly blood in appearance and has a pH of 6
3. Fluid clumps together on the dressing and had a pH of 7
