NCLEX-RN Sample Question

Question

The nurse cares for a client just admitted to the Emergency Center with a suspected head injury. Which action should the nurse take FIRST?

  • 1. Administer dexamethasone (Decadron) 10 mg intravenously.
  • 2. Observe bilateral muscle strength.
  • 3. Assess bilateral deep tendon reflexes.
  • 4. Auscultate bilateral breath sounds.

Answer

1. Administer dexamethasone (Decadron) 10 mg intravenously.

INCORRECT- Not desired; glucocorticoid administration not indicated; will not decrease cerebral edema and intracranial pressure.

2. Observe bilateral muscle strength.

INCORRECT- Desired but not priority; may see contralateral muscle weakness.

3. Assess bilateral deep tendon reflexes.

INCORRECT- Desired but not priority; first priority is assessment of airway, breathing, and circulation.

4. Auscultate bilateral breath sounds.

CORRECT- Desired and priority—assessment of ABCs; cerebral hypoxia will increase intracranial pressure.

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