NUR 445 Exam 3.1 UPDATED ACTUAL Questions and
CORRECT Answers
A 32-year-old male is admitted after a motorcycle crash. Administer mannitol IV
He is increasingly restless, has a severe headache, and 3 multiple choice options
has unequal pupils. His BP is 169/60, HR 48, and RR is
irregular. Which nursing intervention is the priority?
A 71-year-old patient arrives with sudden right-sided Prepare for rt-PA administration
weakness and slurred speech. Symptoms began 45 3 multiple choice options
minutes ago. BP is 170/90. CT scan shows no bleeding.
Which action is appropriate?
A patient with a ruptured aneurysm is admitted to the Hold the medication and notify the provider
ICU. The nurse notes the provider ordered aspirin. What is 3 multiple choice options
the nurse's priority action?
A patient with Guillain-Barré Syndrome reports increasing Prepare for possible intubation
difficulty taking deep breaths. The nurse notes the use of 3 multiple choice options
accessory muscles. What is the priority action?
A patient with ALS reports a new onset of dyspnea and Poor perfusion
cyanosis around the lips. Which finding requires 3 multiple choice options
immediate reporting?
A patient with Myasthenia Gravis is preparing for lunch. Give pyridostigmine 30 minutes before eating
Which action by the nurse is correct? 3 multiple choice options
A patient with trigeminal neuralgia reports severe "Avoid cold drafts to prevent attacks."
unilateral facial pain triggered by cold air. Which teaching 3 multiple choice options
is appropriate?
A patient with a head injury was initially unconscious, then Epidural hematoma
awake and talking, and now rapidly deteriorating. What 3 multiple choice options
condition does the nurse suspect?
A burn patient becomes restless, tachycardic, and has flat Administer isotonic fluids
neck veins. Urine output is 15mL/hr. Which nursing 3 multiple choice options
intervention is a priority?
A patient with an acute MI develops crackles, Intra-aortic balloon pump
hypotension, and decreased urine output. Which nursing 3 multiple choice options
intervention is expected?
A patient with sudden hypotension, JVD, and muffled Pericardiocentesis
heart sounds is suspected of having cardiac tamponade. 3 multiple choice options
What is the priority nursing intervention?
, A patient with a T6 spinal cord injury presents with Atropine
hypotension, bradycardia, and warm dry skin. Which 3 multiple choice options
medication should the nurse anticipate the provider to
order?
A patient stung by a bee arrives with wheezing, stridor, IM epinephrine
and hypotension. What is the first medication the nurse 3 multiple choice options
should prepare to administer?
A patient with sepsis has warm flushed skin, bounding Early sepsis
pulses, and a fever. Which stage is this considered? 3 multiple choice options
A patient with septic shock begins oozing blood from Fresh frozen plasma
their IV site. Which treatment should the nurse anticipate? 3 multiple choice options
A patient with a traumatic brain injury becomes Perform a full neuro assessment
increasingly irritable and reports a worsening headache. 3 multiple choice options
Pupils are equal and reactive. Vitals are stable. What is
the nurse's priority action?
A patient with a subdural hematoma suddenly develops a Impending herniation
unilateral dilated pupil and decerebrate posturing. 3 multiple choice options
A patient with a left-sided ischemic stroke keeps leaving Teach the patient to scan the environment
food on the right side of the tray. What is the most 3 multiple choice options
appropriate nursing intervention?
A patient arrives 2 hours after the onset of stroke Lower BP below 185/110
symptoms. BP is 192/110, and CT shows no bleeding. What 3 multiple choice options
must occur before administering TPA?
A patient with Guillain-Barré Syndrome reports difficulty Notify the provider of possible respiratory failure and prepare for intubation
swallowing and a weak cough. What is the nurse's priority 3 multiple choice options
action?
A patient with ALS has increasing difficulty clearing Pneumonia
secretions and a weak cough. Which complication is most 3 multiple choice options
likely to develop?
A patient with Myasthenia Gravis develops bradycardia, Cholinergic crisis
sweating, and excessive secretions after taking 3 multiple choice options
medication. What does this indicate?
A patient reports sharp, stabbing facial pain triggered by CN V
brushing teeth. Which cranial nerve is being affected? 3 multiple choice options
A patient with a head injury has a slow neurological Subdural hematoma
decline over 48 hours. Which condition does this 3 multiple choice options
indicate?
CORRECT Answers
A 32-year-old male is admitted after a motorcycle crash. Administer mannitol IV
He is increasingly restless, has a severe headache, and 3 multiple choice options
has unequal pupils. His BP is 169/60, HR 48, and RR is
irregular. Which nursing intervention is the priority?
A 71-year-old patient arrives with sudden right-sided Prepare for rt-PA administration
weakness and slurred speech. Symptoms began 45 3 multiple choice options
minutes ago. BP is 170/90. CT scan shows no bleeding.
Which action is appropriate?
A patient with a ruptured aneurysm is admitted to the Hold the medication and notify the provider
ICU. The nurse notes the provider ordered aspirin. What is 3 multiple choice options
the nurse's priority action?
A patient with Guillain-Barré Syndrome reports increasing Prepare for possible intubation
difficulty taking deep breaths. The nurse notes the use of 3 multiple choice options
accessory muscles. What is the priority action?
A patient with ALS reports a new onset of dyspnea and Poor perfusion
cyanosis around the lips. Which finding requires 3 multiple choice options
immediate reporting?
A patient with Myasthenia Gravis is preparing for lunch. Give pyridostigmine 30 minutes before eating
Which action by the nurse is correct? 3 multiple choice options
A patient with trigeminal neuralgia reports severe "Avoid cold drafts to prevent attacks."
unilateral facial pain triggered by cold air. Which teaching 3 multiple choice options
is appropriate?
A patient with a head injury was initially unconscious, then Epidural hematoma
awake and talking, and now rapidly deteriorating. What 3 multiple choice options
condition does the nurse suspect?
A burn patient becomes restless, tachycardic, and has flat Administer isotonic fluids
neck veins. Urine output is 15mL/hr. Which nursing 3 multiple choice options
intervention is a priority?
A patient with an acute MI develops crackles, Intra-aortic balloon pump
hypotension, and decreased urine output. Which nursing 3 multiple choice options
intervention is expected?
A patient with sudden hypotension, JVD, and muffled Pericardiocentesis
heart sounds is suspected of having cardiac tamponade. 3 multiple choice options
What is the priority nursing intervention?
, A patient with a T6 spinal cord injury presents with Atropine
hypotension, bradycardia, and warm dry skin. Which 3 multiple choice options
medication should the nurse anticipate the provider to
order?
A patient stung by a bee arrives with wheezing, stridor, IM epinephrine
and hypotension. What is the first medication the nurse 3 multiple choice options
should prepare to administer?
A patient with sepsis has warm flushed skin, bounding Early sepsis
pulses, and a fever. Which stage is this considered? 3 multiple choice options
A patient with septic shock begins oozing blood from Fresh frozen plasma
their IV site. Which treatment should the nurse anticipate? 3 multiple choice options
A patient with a traumatic brain injury becomes Perform a full neuro assessment
increasingly irritable and reports a worsening headache. 3 multiple choice options
Pupils are equal and reactive. Vitals are stable. What is
the nurse's priority action?
A patient with a subdural hematoma suddenly develops a Impending herniation
unilateral dilated pupil and decerebrate posturing. 3 multiple choice options
A patient with a left-sided ischemic stroke keeps leaving Teach the patient to scan the environment
food on the right side of the tray. What is the most 3 multiple choice options
appropriate nursing intervention?
A patient arrives 2 hours after the onset of stroke Lower BP below 185/110
symptoms. BP is 192/110, and CT shows no bleeding. What 3 multiple choice options
must occur before administering TPA?
A patient with Guillain-Barré Syndrome reports difficulty Notify the provider of possible respiratory failure and prepare for intubation
swallowing and a weak cough. What is the nurse's priority 3 multiple choice options
action?
A patient with ALS has increasing difficulty clearing Pneumonia
secretions and a weak cough. Which complication is most 3 multiple choice options
likely to develop?
A patient with Myasthenia Gravis develops bradycardia, Cholinergic crisis
sweating, and excessive secretions after taking 3 multiple choice options
medication. What does this indicate?
A patient reports sharp, stabbing facial pain triggered by CN V
brushing teeth. Which cranial nerve is being affected? 3 multiple choice options
A patient with a head injury has a slow neurological Subdural hematoma
decline over 48 hours. Which condition does this 3 multiple choice options
indicate?
