19/06/2025, 13:07 Uworld NCLEX Questions and Answers EXAM (2025) QUESTIONS AND (DETAILED ANSWERS) WITH COMPLETE SOLUTION…
Uworld NCLEX Questions and Answers EXAM
(2025) QUESTIONS AND (DETAILED ANSWERS)
WITH COMPLETE SOLUTIONS
Save
Terms in this set (20)
2. Increasing temperature, The nurse is caring for the client with increased
decreasing pulse, intracranial pressure. The nurse would note which
decreasing respirations, trend in vital signs if the intracranial pressure is rising?
increasing blood pressure
1. Increasing temperature, increasing pulse, increasing
A change in vital signs respirations, decreasing blood pressure
may be a late sign of 2. Increasing temperature, decreasing pulse,
increased intracranial decreasing respirations, decreasing blood pressure
pressure. Trends include 3. Decreasing temperature, decreasing pulse,
increasing temperature increasing respirations, decreasing blood pressure
and blood pressure and 4. Decreasing temperature, increasing pulse,
decreasing pulse and decreasing respirations, increasing blood pressure
respirations. Respiratory
irregularities also may
occur.
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,19/06/2025, 13:07 Uworld NCLEX Questions and Answers EXAM (2025) QUESTIONS AND (DETAILED ANSWERS) WITH COMPLETE SOLUTION…
2, 3, 4 The nurse has established a goal to maintain
The nurse should maintain intracranial pressure (ICP) within the normal range for
ICP by elevating the head a client who had a craniotomy 12 hours ago. What
of the bed 15 - 20 degrees should the nurse do? Select all that apply.
and monitoring
neurologic status. An ICP 1. Encourage the client to cough to expectorate
>15 mmHg with 20 to 25 secretions.
mmHg as upper limits of 2. Elevate the head of the bed 15 - 20 degrees.
normal indicates 3. Contact the HCP if ICP is >15 mmHg.
increased ICP, and the 4. Monitor neurologic status using the Glasgow Coma
nurse should notify the Scale.
HCP. Coughing and range 5. Stimulate the client with active range-of-motion
of motion exercises will exercises.
increase ICP and should
be avoided in the early
postoperative stage.
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, 19/06/2025, 13:07 Uworld NCLEX Questions and Answers EXAM (2025) QUESTIONS AND (DETAILED ANSWERS) WITH COMPLETE SOLUTION…
3 What should the nurse do first when a client with a
The clear drainage must head injury begins to have clear drainage from the
be analyzed to determine nose?
whether it is nasal
drainage or CSF. The nurse 1. Compress the nares
should not give the client 2. Tilt the head back
tissues because it is 3. Collect the drainage
important to know how 4. Administer an antihistamine for postnasal drip
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.
4 A client has clear fluid leaking from the nose
Leakage of cerebrospinal following a basilar skull fracture. Which finding would
fluid from the ears or nose alert the nurse that cerebrospinal fluid is present?
may accompany basilar
skull fractures. CSF can be 1. Fluid is clear and tests negative for glucose.
distinguished from other 2. Fluid is grossly blood in appearance and has a pH
body fluids because the of 6
drainage will separate into 3. Fluid clumps together on the dressing and had a
bloody and yellow pH of 7
concentric rings on Fluid separates into concentric rings and tests
dressing material, called a positive for glucose.
halo sign. The fluid also
tests positive for glucose.
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Uworld NCLEX Questions and Answers EXAM
(2025) QUESTIONS AND (DETAILED ANSWERS)
WITH COMPLETE SOLUTIONS
Save
Terms in this set (20)
2. Increasing temperature, The nurse is caring for the client with increased
decreasing pulse, intracranial pressure. The nurse would note which
decreasing respirations, trend in vital signs if the intracranial pressure is rising?
increasing blood pressure
1. Increasing temperature, increasing pulse, increasing
A change in vital signs respirations, decreasing blood pressure
may be a late sign of 2. Increasing temperature, decreasing pulse,
increased intracranial decreasing respirations, decreasing blood pressure
pressure. Trends include 3. Decreasing temperature, decreasing pulse,
increasing temperature increasing respirations, decreasing blood pressure
and blood pressure and 4. Decreasing temperature, increasing pulse,
decreasing pulse and decreasing respirations, increasing blood pressure
respirations. Respiratory
irregularities also may
occur.
https://quizlet.com/1055562597/uworld-nclex-questions-and-answers-exam-2025-questions-and-detailed-answers-with-complete-solutions-flash-card… 1/28
,19/06/2025, 13:07 Uworld NCLEX Questions and Answers EXAM (2025) QUESTIONS AND (DETAILED ANSWERS) WITH COMPLETE SOLUTION…
2, 3, 4 The nurse has established a goal to maintain
The nurse should maintain intracranial pressure (ICP) within the normal range for
ICP by elevating the head a client who had a craniotomy 12 hours ago. What
of the bed 15 - 20 degrees should the nurse do? Select all that apply.
and monitoring
neurologic status. An ICP 1. Encourage the client to cough to expectorate
>15 mmHg with 20 to 25 secretions.
mmHg as upper limits of 2. Elevate the head of the bed 15 - 20 degrees.
normal indicates 3. Contact the HCP if ICP is >15 mmHg.
increased ICP, and the 4. Monitor neurologic status using the Glasgow Coma
nurse should notify the Scale.
HCP. Coughing and range 5. Stimulate the client with active range-of-motion
of motion exercises will exercises.
increase ICP and should
be avoided in the early
postoperative stage.
https://quizlet.com/1055562597/uworld-nclex-questions-and-answers-exam-2025-questions-and-detailed-answers-with-complete-solutions-flash-card… 2/28
, 19/06/2025, 13:07 Uworld NCLEX Questions and Answers EXAM (2025) QUESTIONS AND (DETAILED ANSWERS) WITH COMPLETE SOLUTION…
3 What should the nurse do first when a client with a
The clear drainage must head injury begins to have clear drainage from the
be analyzed to determine nose?
whether it is nasal
drainage or CSF. The nurse 1. Compress the nares
should not give the client 2. Tilt the head back
tissues because it is 3. Collect the drainage
important to know how 4. Administer an antihistamine for postnasal drip
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.
4 A client has clear fluid leaking from the nose
Leakage of cerebrospinal following a basilar skull fracture. Which finding would
fluid from the ears or nose alert the nurse that cerebrospinal fluid is present?
may accompany basilar
skull fractures. CSF can be 1. Fluid is clear and tests negative for glucose.
distinguished from other 2. Fluid is grossly blood in appearance and has a pH
body fluids because the of 6
drainage will separate into 3. Fluid clumps together on the dressing and had a
bloody and yellow pH of 7
concentric rings on Fluid separates into concentric rings and tests
dressing material, called a positive for glucose.
halo sign. The fluid also
tests positive for glucose.
https://quizlet.com/1055562597/uworld-nclex-questions-and-answers-exam-2025-questions-and-detailed-answers-with-complete-solutions-flash-card… 3/28
