A client with a traumatic brain injury from a motor vehicle crash is being monitored in the intensive care unit. The client's intracranial pressure (ICP) is $22 \mathrm{mmHg}$. Which nursing intervention is appropriate based on this finding?

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Question 1 of 5

A client with a traumatic brain injury from a motor vehicle crash is being monitored in the intensive care unit. The client's intracranial pressure (ICP) is $22 \mathrm{mmHg}$. Which nursing intervention is appropriate based on this finding?

Correct Answer: C

Rationale: ICP of 22 mmHg (elevated >20) requires mannitol (C) to reduce cerebral edema osmotically. Saline bolus (A) may worsen ICP. Flat bed (B) increases pressure. Coughing (D) raises ICP. C is correct. Rationale: Mannitol lowers ICP swiftly, a standard intervention in brain injury, per neurocritical care, preventing herniation unlike contraindicated actions.

Question 2 of 5

When does the nurse chart an intervention that involves administering medication to a client?

Correct Answer: D

Rationale: Charting a medication intervention immediately after administration ensures accuracy and legal protection. Delaying until the shift ends, before the next dose, or within an hour risks forgetting details like dosage or client response compromising the record's reliability. Immediate documentation captures the exact time and outcome, such as pain relief post-analgesic, critical if issues arise later. This practice upholds standards, supports continuity of care, and defends the nurse in potential disputes, reflecting the urgency of real-time recording in dynamic clinical settings.

Question 3 of 5

Your assigned client has a leg ulcer that has a dressing on it. During your assessment, you find that the dressing is wet. The client admits to spilling water on the dressing. What action would be best on your part?

Correct Answer: B

Rationale: A wet dressing from water spill requires removal and replacement to prevent infection and maintain a healing environment. Reinforcing keeps moisture, drying with a hairdryer risks burns or contamination, and air drying is slow and ineffective. This action ensures wound integrity, a core nursing responsibility.

Question 4 of 5

When weighing a client daily, you will most need to weigh the client at which of the following times?

Correct Answer: B

Rationale: Weighing a client at the same time daily ensures consistency, accounting for fluid and food variations. Rest, post-bath, or priority timing lacks this precision. Nurses use this for accurate monitoring.

Question 5 of 5

When pain impulses are transmitted via the A-delta fibers, which of the following types of pain will your client have?

Correct Answer: A

Rationale: A-delta fibers transmit sharp, pricking pain, fast and localized, unlike throbbing, burning, or stabbing via C-fibers. Nurses recognize this for pain type assessment.

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