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Question 1 of 5

The client with a closed head injury is admitted to the neurointensive care department following a motor-vehicle accident. Which goal is an appropriate short-term goal for the client?

Correct Answer: C

Rationale: Maintaining ICP <15 mm Hg is a critical short-term goal in head injury to prevent brain damage, per neuro ICU standards.

Question 2 of 5

Which action by the unlicensed assistive personnel (UAP) requires intervention by the nurse?

Correct Answer: D

Rationale: Wiping back to front risks UTI, requiring intervention; other actions are appropriate.

Question 3 of 5

The nurse is teaching a 28-year-old client who was recently prescribed birth control pills. Which statement by the client indicates teaching has been effective?

Correct Answer: A

Rationale: Antibiotics (e.g., rifampin) reduce oral contraceptive efficacy, requiring backup methods, indicating effective teaching. Missing pills, patch preference, or ring replacement are incorrect.

Question 4 of 5

Which expected outcome should be included in the plan of care for a postoperative client practicing guided imagery?

Correct Answer: B

Rationale: Guided imagery reduces pain perception, so a decreased pain score is the expected outcome. WBC count, urine output, and dressing drainage are unrelated.

Question 5 of 5

The nurse is initiating a blood transfusion. Which interventions should the nurse implement? Select all that apply.

Correct Answer: A,B,E

Rationale: Lung assessment monitors for transfusion reactions, consent ensures informed care, and order verification confirms accuracy.

Similar Questions

Which assessment information is the most critical indicator of a neurological deficit?
The nurse is admitting the client to a medical unit. Which questions should the nurse specifically ask the client about the current use of medications? Select all that apply.
The rehabilitation nurse is caring for an elderly client who had a surgical repair of a fractured hip. The client states she misses her dog. Which intervention should the nurse implement?
Which interventions should the emergency department nurse implement for a client who has an AP of 122 and a BP of 80/50? Select all that apply.
Which information would be most important for the public health department nurse to obtain before giving the client condoms?

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