NUR 265
EXAM 3 PRACTICE QUESTIONS
,QUESTION #1
The nurse is working in the emergency department • Patients taking warfarin are at a
(ED) is admitting a client who has sustained a traumatic
higher risk for bleeding and will
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 will
at risk for developing increased intracranial pressure
(ICP). Which of the following actions should the nurse flex the hips because this causes
take when caring for this client? an increase in ICP. Therefore, A
&C are incorrect. PaCO2 is still in
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 batches
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.
EXAM 3 PRACTICE QUESTIONS
,QUESTION #1
The nurse is working in the emergency department • Patients taking warfarin are at a
(ED) is admitting a client who has sustained a traumatic
higher risk for bleeding and will
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 will
at risk for developing increased intracranial pressure
(ICP). Which of the following actions should the nurse flex the hips because this causes
take when caring for this client? an increase in ICP. Therefore, A
&C are incorrect. PaCO2 is still in
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 batches
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.
