30. A client admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, “I have a pounding headache and l feel sick to my stomach ” Which action should the nurse take first?  

20. After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a client with a traumatic head injury has increased from 14 to 17 mmHg. Which action should the nurse take first?

35. A client with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?

11. Which prescribed drug is best for the nurse to administer prior to scheduled wound debridement and dressing change on a client with partial-thickness burns?  

20. After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a client with a traumatic head injury has increased from 14 to 17 mmHg. Which action should the nurse take first?

30. A client admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, “I have a pounding headache and l feel sick to my stomach ” Which action should the nurse take first?  

58.  Priority nursing management for a client who has developed multi-organ dysfunction syndrome (MODS) would include which intervention.

29.  The nurse should monitor the child for which finding to help confirm the diagnosis of lead poisoning? (Select all that apply)

44. The nurse is assessing a client with ecchymosis for a basilar skull fracture.  The nurse should assess which area for potential confirmation of this type of injury in the client?     

48. The nurse is caring for a client who has a head injury and fractured right arm after being assaulted. He is examined by the primary health care provider (PHCP) and the CT scan identifies an acute subdural hematoma. Which assessment information requires rapid action by the nurse?