Critical Care exam 3
CRITICAL CARE EXAM 3 NEWEST 2025/2026 COMPLETE ALL
QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+||BRAND NEW VERSION!
A nurse is caring for a client who has a spinal cord injury at the level of T4. Which
of the following findings should indicate the presence of autonomic dysreflexia?
A. Heart rate of 58 bpm
B. Pale, cool lower extremities
C. Blood pressure of 190/110 mm Hg
D. Respiratory rate of 10/min
Correct Answer: C. Blood pressure of 190/110 mm Hg
Rationale: A sudden, severe elevation in blood pressure is a hallmark of
autonomic dysreflexia, a life-threatening complication typically occurring in clients
with spinal cord injuries at or above T6. It is triggered by stimuli such as bladder
distention or fecal impaction. Other cues may include bradycardia, headache,
flushed skin above injury level, and diaphoresis.
A client with a spinal cord injury at C6 is at risk for which of the following
complications?
A. Stress fractures
B. Urinary incontinence
C. Neurogenic shock
D. Loss of upper limb function
Correct Answer: C. Neurogenic shock
Rationale: Injuries above T6 place clients at risk for neurogenic shock, which
presents with hypotension, bradycardia, and warm, dry skin due to loss of
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sympathetic tone. Loss of upper limb function occurs at C4 or higher, and stress
fractures aren't the immediate concern.
A nurse is planning care for a client with paraplegia from a T10 spinal cord injury.
Which of the following interventions is a priority to prevent complications?
A. Perform passive range-of-motion exercises
B. Administer stool softeners daily
C. Apply compression stockings
D. Reposition the client every 2 hours
Correct Answer: D. Reposition the client every 2 hours
Rationale: Skin integrity is a priority concern for immobile clients. Regular
repositioning helps prevent pressure ulcers. This supports Physiological Integrity in
the NCLEX framework.
A nurse is caring for a client with a complete spinal cord injury at the cervical level.
Which assessment finding requires immediate intervention?
A. Weak cough reflex
B. Hypoactive bowel sounds
C. Blood pressure 92/56 mm Hg
D. Diminished lower extremity reflexes
Correct Answer: A. Weak cough reflex
Rationale: A cervical injury can impair diaphragm and intercostal function,
increasing risk for ineffective airway clearance. A weak cough reflex can lead to
secretion retention and pneumonia. Airway always comes first in ABC
prioritization.
A nurse is teaching a client with a new T6 spinal cord injury about bladder
management. Which of the following statements indicates understanding?
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A. "I'll be able to tell when my bladder is full."
B. "I will need to do intermittent catheterization."
C. "I'll have a Foley catheter for the rest of my life."
D. "I won't need to worry about urinary problems."
Correct Answer: B. "I will need to do intermittent catheterization."
Rationale: Neurogenic bladder is common after SCI. Intermittent self-
catheterization promotes independence and reduces the risk of infection
compared to indwelling catheters.
A client with a recent spinal cord injury complains of severe headache, blurred
vision, and flushing above the injury site. What is the nurse's priority action?
A. Check the urinary catheter for kinks or obstruction
B. Notify the provider immediately
C. Administer prescribed antihypertensive
D. Reassure the client and elevate the head of the bed
Correct Answer: A. Check the urinary catheter for kinks or obstruction
Rationale: Autonomic dysreflexia is often triggered by bladder distention, so the
first action is to eliminate the cause. Removing the noxious stimulus can stop the
reaction quickly. This aligns with NGN "Take Action" and ABC/safety-first priorities.
Which of the following nursing interventions is appropriate to include in the plan
of care for a client with a high thoracic spinal cord injury to prevent complications
from immobility?
A. Limit fluid intake to prevent bladder distention
B. Keep the head of the bed elevated at all times
C. Encourage incentive spirometer use every 2 hours
D. Restrict caloric intake to avoid weight gain
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Correct Answer: C. Encourage incentive spirometer use every 2 hours
Rationale: Although thoracic injuries don't directly impact respiratory muscles like
cervical injuries, lung expansion can be reduced by immobility. Using an incentive
spirometer helps prevent atelectasis and pneumonia.
A nurse is assessing a client with a suspected small bowel obstruction. Which of
the following findings should the nurse expect?
A. Large-volume bloody diarrhea
B. Hypoactive bowel sounds and flat abdomen
C. Visible peristaltic waves and high-pitched bowel sounds
D. Right upper quadrant rebound tenderness
Correct Answer: C. Visible peristaltic waves and high-pitched bowel sounds
Rationale: Small bowel obstructions typically present with colicky abdominal pain,
visible peristalsis, and high-pitched or tinkling bowel sounds due to intestinal
dilation. As the obstruction progresses, bowel sounds may diminish. Diarrhea and
rebound tenderness are not typical.
A client with a traumatic brain injury is demonstrating increased restlessness and
a decreased level of consciousness. What is the priority nursing action?
A. Elevate the head of the bed to 30 degrees
B. Administer prescribed sedatives
C. Assess for a urinary tract infection
D. Provide passive range of motion exercises
Correct Answer: A. Elevate the head of the bed to 30 degrees
Rationale: Elevating the HOB to 30° promotes venous drainage and reduces
intracranial pressure (ICP), a life-threatening complication in TBI. This is a priority
action under the "Disability" component of the ABCDE
4|Page
CRITICAL CARE EXAM 3 NEWEST 2025/2026 COMPLETE ALL
QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+||BRAND NEW VERSION!
A nurse is caring for a client who has a spinal cord injury at the level of T4. Which
of the following findings should indicate the presence of autonomic dysreflexia?
A. Heart rate of 58 bpm
B. Pale, cool lower extremities
C. Blood pressure of 190/110 mm Hg
D. Respiratory rate of 10/min
Correct Answer: C. Blood pressure of 190/110 mm Hg
Rationale: A sudden, severe elevation in blood pressure is a hallmark of
autonomic dysreflexia, a life-threatening complication typically occurring in clients
with spinal cord injuries at or above T6. It is triggered by stimuli such as bladder
distention or fecal impaction. Other cues may include bradycardia, headache,
flushed skin above injury level, and diaphoresis.
A client with a spinal cord injury at C6 is at risk for which of the following
complications?
A. Stress fractures
B. Urinary incontinence
C. Neurogenic shock
D. Loss of upper limb function
Correct Answer: C. Neurogenic shock
Rationale: Injuries above T6 place clients at risk for neurogenic shock, which
presents with hypotension, bradycardia, and warm, dry skin due to loss of
1|Page
, Critical Care exam 3
sympathetic tone. Loss of upper limb function occurs at C4 or higher, and stress
fractures aren't the immediate concern.
A nurse is planning care for a client with paraplegia from a T10 spinal cord injury.
Which of the following interventions is a priority to prevent complications?
A. Perform passive range-of-motion exercises
B. Administer stool softeners daily
C. Apply compression stockings
D. Reposition the client every 2 hours
Correct Answer: D. Reposition the client every 2 hours
Rationale: Skin integrity is a priority concern for immobile clients. Regular
repositioning helps prevent pressure ulcers. This supports Physiological Integrity in
the NCLEX framework.
A nurse is caring for a client with a complete spinal cord injury at the cervical level.
Which assessment finding requires immediate intervention?
A. Weak cough reflex
B. Hypoactive bowel sounds
C. Blood pressure 92/56 mm Hg
D. Diminished lower extremity reflexes
Correct Answer: A. Weak cough reflex
Rationale: A cervical injury can impair diaphragm and intercostal function,
increasing risk for ineffective airway clearance. A weak cough reflex can lead to
secretion retention and pneumonia. Airway always comes first in ABC
prioritization.
A nurse is teaching a client with a new T6 spinal cord injury about bladder
management. Which of the following statements indicates understanding?
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, Critical Care exam 3
A. "I'll be able to tell when my bladder is full."
B. "I will need to do intermittent catheterization."
C. "I'll have a Foley catheter for the rest of my life."
D. "I won't need to worry about urinary problems."
Correct Answer: B. "I will need to do intermittent catheterization."
Rationale: Neurogenic bladder is common after SCI. Intermittent self-
catheterization promotes independence and reduces the risk of infection
compared to indwelling catheters.
A client with a recent spinal cord injury complains of severe headache, blurred
vision, and flushing above the injury site. What is the nurse's priority action?
A. Check the urinary catheter for kinks or obstruction
B. Notify the provider immediately
C. Administer prescribed antihypertensive
D. Reassure the client and elevate the head of the bed
Correct Answer: A. Check the urinary catheter for kinks or obstruction
Rationale: Autonomic dysreflexia is often triggered by bladder distention, so the
first action is to eliminate the cause. Removing the noxious stimulus can stop the
reaction quickly. This aligns with NGN "Take Action" and ABC/safety-first priorities.
Which of the following nursing interventions is appropriate to include in the plan
of care for a client with a high thoracic spinal cord injury to prevent complications
from immobility?
A. Limit fluid intake to prevent bladder distention
B. Keep the head of the bed elevated at all times
C. Encourage incentive spirometer use every 2 hours
D. Restrict caloric intake to avoid weight gain
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, Critical Care exam 3
Correct Answer: C. Encourage incentive spirometer use every 2 hours
Rationale: Although thoracic injuries don't directly impact respiratory muscles like
cervical injuries, lung expansion can be reduced by immobility. Using an incentive
spirometer helps prevent atelectasis and pneumonia.
A nurse is assessing a client with a suspected small bowel obstruction. Which of
the following findings should the nurse expect?
A. Large-volume bloody diarrhea
B. Hypoactive bowel sounds and flat abdomen
C. Visible peristaltic waves and high-pitched bowel sounds
D. Right upper quadrant rebound tenderness
Correct Answer: C. Visible peristaltic waves and high-pitched bowel sounds
Rationale: Small bowel obstructions typically present with colicky abdominal pain,
visible peristalsis, and high-pitched or tinkling bowel sounds due to intestinal
dilation. As the obstruction progresses, bowel sounds may diminish. Diarrhea and
rebound tenderness are not typical.
A client with a traumatic brain injury is demonstrating increased restlessness and
a decreased level of consciousness. What is the priority nursing action?
A. Elevate the head of the bed to 30 degrees
B. Administer prescribed sedatives
C. Assess for a urinary tract infection
D. Provide passive range of motion exercises
Correct Answer: A. Elevate the head of the bed to 30 degrees
Rationale: Elevating the HOB to 30° promotes venous drainage and reduces
intracranial pressure (ICP), a life-threatening complication in TBI. This is a priority
action under the "Disability" component of the ABCDE
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