NUR 265 EXAM 3 REVIEW - QUESTIONS
AND ANSWERS | LATEST UPDATE
2026/2027
RN working in ED and is admitting a pt who has TBI from MVC-- what is the priority to
notify to PCP - ANSWERStakes warfarin daily--there could be a hemorrhage as part of
the injury. warfarin is a blood thinner
Newly hired nurse caring for a pt who has a closed head injury, on a vent, at risk for
ICP--what action requires intervention? - ANSWERSraising the foot of the pt beds--
maintain the head midline/neutral position to prevent increased ICP
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--what requires intervention ? -
ANSWERSclustering pt care/activities-- cluster care= increased ICP
assessing pts for the risk of sustaining TBI, which of the following pts should the nurse
identity as the greatest risk? - ANSWERS20 year old college student who is on the
football team.
Nurse w assigned pts. which assessment finding would need to be reported to PCP? -
ANSWERSthe development of asymmetric pupils with no reaction to light in the pt who
has a TBI-- pupillary changes;
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the pt has rhinorrhea
and it is positive for glucose--what action is next? - ANSWERSperform a halo sign test--
CSG leaking, lab test will be analyzed for glucose and electrolyte content. place fluid on
a while absorbent paper/linen
nurse providing dc teaching to pts partner who sustained a mild head injury from MVC.
--what statement requires additional teaching? - ANSWERSI will bring my partner to the
ED if they immediately start vomiting--symptoms usually resolve within 72 hrs NV is
expected.
Nurse is caring for the following pt. which pt would the nurse see first? - ANSWERSthe
pt who has a brain injury and a BP change from 110/58 to 134/40-- cushings triad.
severe htn, widening pulse pressure, bradycardia
24 hr post op craniotomy. pt is reporting headach 8/10-- what is the next step for the
nurse to take? - ANSWERSperform a neuro assessment--minimize ICP, assess the
problem.
AND ANSWERS | LATEST UPDATE
2026/2027
RN working in ED and is admitting a pt who has TBI from MVC-- what is the priority to
notify to PCP - ANSWERStakes warfarin daily--there could be a hemorrhage as part of
the injury. warfarin is a blood thinner
Newly hired nurse caring for a pt who has a closed head injury, on a vent, at risk for
ICP--what action requires intervention? - ANSWERSraising the foot of the pt beds--
maintain the head midline/neutral position to prevent increased ICP
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP--what requires intervention ? -
ANSWERSclustering pt care/activities-- cluster care= increased ICP
assessing pts for the risk of sustaining TBI, which of the following pts should the nurse
identity as the greatest risk? - ANSWERS20 year old college student who is on the
football team.
Nurse w assigned pts. which assessment finding would need to be reported to PCP? -
ANSWERSthe development of asymmetric pupils with no reaction to light in the pt who
has a TBI-- pupillary changes;
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the pt has rhinorrhea
and it is positive for glucose--what action is next? - ANSWERSperform a halo sign test--
CSG leaking, lab test will be analyzed for glucose and electrolyte content. place fluid on
a while absorbent paper/linen
nurse providing dc teaching to pts partner who sustained a mild head injury from MVC.
--what statement requires additional teaching? - ANSWERSI will bring my partner to the
ED if they immediately start vomiting--symptoms usually resolve within 72 hrs NV is
expected.
Nurse is caring for the following pt. which pt would the nurse see first? - ANSWERSthe
pt who has a brain injury and a BP change from 110/58 to 134/40-- cushings triad.
severe htn, widening pulse pressure, bradycardia
24 hr post op craniotomy. pt is reporting headach 8/10-- what is the next step for the
nurse to take? - ANSWERSperform a neuro assessment--minimize ICP, assess the
problem.
