NUR 265
EXAM 3 PRACTICE QUESTIONS
,QUESTION #1
The nurse is working in the emergency department • Patients taking warfarin are a
(ED) is admitting a client who has sustained a traumatic
higher risk for bleeding and w
brain injury (TBI) following a motor vehicle crash. It is a
priority for the nurse to notify the primary health care need to be scanned for a
provider (PHCP) if the client hematoma.
a. has a blood pressure of 162/94 mm Hg.
b. is unable to remember the crash.
c. reports having a continuous headache.
d. *takes prescribed warfarin daily.
,QUESTION #2
The nurse is caring for a client who sustained a closed • You do not want to move the
head injury, is receiving mechanical ventilation, and is
client into any position that w
at risk for developing increased intracranial pressure
(ICP). Which of the following actions should the nurse flex the hips because this cau
take when caring for this client? an increase in ICP. Therefore,
&C are incorrect. PaCO2 is sti
a. Perform passive range of motion (ROM) to the
client’s hips and knees. normal range and is not a
b. Notify the charge nurse if the client’s PaCO2 concern for ICP.
decreases from 39 mm Hg to 35 mm Hg.
c. Elevate the foot of the client’s bed.
d. *Log roll the client during turning and
repositioning.
,QUESTION #3
The newly hired nurse is caring for a client who was • A, B & D are all activities that
admitted 12 hours ago with a traumatic brain injury
will increase ICP. You want to
(TBI) and is at risk for developing increased intracranial
pressure (ICP). It indicates correct client care if the provide care in smaller batche
nurse preceptor observes the newly hired nurse of work to not overstimulate
them. Coughing and deep
a. clustering client care activities.
b. having the client cough and deep breathe every breathing can increase ICP as
hour. well as ROM on the hips.
c. *instructing the client not to assist during
repositioning.
d. performing range-of-motion (ROM) exercises of the
client’s hips.
, QUESTION #4
The nurse is assessing clients for the risk of sustaining a • Younger adults are at a great
traumatic brain injury (TBI). Which of the following clients
should the nurse identify as being at greatest risk? risk for sustaining a TBI
including concussions from
a. 7-year-old who is learning how to ride a bicycle without
training wheels. sports or falls.
b. *20-year-old college student who participates on the
football team.
c. 45-year-old who has epilepsy and takes prescribed
phenytoin.
d. 60-year-old who lives alone and wears a hearing aid.
EXAM 3 PRACTICE QUESTIONS
,QUESTION #1
The nurse is working in the emergency department • Patients taking warfarin are a
(ED) is admitting a client who has sustained a traumatic
higher risk for bleeding and w
brain injury (TBI) following a motor vehicle crash. It is a
priority for the nurse to notify the primary health care need to be scanned for a
provider (PHCP) if the client hematoma.
a. has a blood pressure of 162/94 mm Hg.
b. is unable to remember the crash.
c. reports having a continuous headache.
d. *takes prescribed warfarin daily.
,QUESTION #2
The nurse is caring for a client who sustained a closed • You do not want to move the
head injury, is receiving mechanical ventilation, and is
client into any position that w
at risk for developing increased intracranial pressure
(ICP). Which of the following actions should the nurse flex the hips because this cau
take when caring for this client? an increase in ICP. Therefore,
&C are incorrect. PaCO2 is sti
a. Perform passive range of motion (ROM) to the
client’s hips and knees. normal range and is not a
b. Notify the charge nurse if the client’s PaCO2 concern for ICP.
decreases from 39 mm Hg to 35 mm Hg.
c. Elevate the foot of the client’s bed.
d. *Log roll the client during turning and
repositioning.
,QUESTION #3
The newly hired nurse is caring for a client who was • A, B & D are all activities that
admitted 12 hours ago with a traumatic brain injury
will increase ICP. You want to
(TBI) and is at risk for developing increased intracranial
pressure (ICP). It indicates correct client care if the provide care in smaller batche
nurse preceptor observes the newly hired nurse of work to not overstimulate
them. Coughing and deep
a. clustering client care activities.
b. having the client cough and deep breathe every breathing can increase ICP as
hour. well as ROM on the hips.
c. *instructing the client not to assist during
repositioning.
d. performing range-of-motion (ROM) exercises of the
client’s hips.
, QUESTION #4
The nurse is assessing clients for the risk of sustaining a • Younger adults are at a great
traumatic brain injury (TBI). Which of the following clients
should the nurse identify as being at greatest risk? risk for sustaining a TBI
including concussions from
a. 7-year-old who is learning how to ride a bicycle without
training wheels. sports or falls.
b. *20-year-old college student who participates on the
football team.
c. 45-year-old who has epilepsy and takes prescribed
phenytoin.
d. 60-year-old who lives alone and wears a hearing aid.
