EXAM 2025-2026 WITH 100% CORRECT
ANSWERS GRADED A+
The nurse is caring for a client who sustained burns to
the mouth. During the change-of-shift assessment, the
nurse notes that this client has fine wheezes. Two hours
later the nurse notes that the client is no longer
wheezing. Which of the following actions should the nurse
take next?
Gather equipment in preparation for intubation.
3 multiple choice options
The nurse is caring for an adult client who was recently
admitted with a head injury following a motor vehicle
crash. One hour ago, the client's vital signs (VS) were
temperature (T): 98.6° F; pulse (P): 110; respirations (R):
26; blood pressure (BP): 128/68 mm Hg. Which of the
following findings is a priority for the nurse to follow up?
P: 56; R: 14; BP: 166/52 mm Hg.
3 multiple choice options
,The nurse is caring for a client who sustained a closed
head injury, is receiving mechanical ventilation, and is at
risk for developing increased intracranial pressure (ICP).
Which of the following actions should the nurse take
when caring for this client?
Log roll the client during turning and repositioning.
3 multiple choice options
The newly hired nurse is caring for a client who was
admitted 12 hours ago with a traumatic brain injury (TBI),
is intubated, and is at risk for developing increased
intracranial pressure (ICP). Which interventions from the
box below should the nurse include in the client's plan of
care?
Avoid clustering client care activities, Provide a quiet
environment by limiting visitors, Hyper oxygenate the
client before and after suctioning, Avoid maintaining hips
in a flexed position.
2 multiple choice options
The nurse working in the intensive care unit (ICU) is
assessing a client who sustained a basilar skull fracture
24 hours ago. It is most important to follow up with the
primary health care provider (PHCP) if the client
, becomes irritable and restless.
3 multiple choice options
The nurse is assessing a client who has experienced a
mild traumatic brain injury (TBI). Which findings from the
box below are consistent with this diagnosis?
Dizziness and gait problems, Increased sensitivity to light
or noise, Amnesia about the events around the time of
injury.
3 multiple choice options
The nurse is providing discharge instructions to the
parents of a 15-year-old female who sustained a
concussion while playing field back Which of the following
statements by a parent indicates a need for further
teaching?
"We should avoid giving any acetaminophen to treat
headaches.
3 multiple choice options
The nurse is assessing clients for the risk of sustaining a
traumatic brain injury (TBI). Which of the following clients
should the nurse identify as being at greatest risk?