Nur 265 exam 3 UPDATED ACTUAL Questions and CORRECT Answers
The nurse is working in the emergency takes prescribed warfarin daily
department and is admitting a client who
has a sustained TBI, following a motor
vehicle crash, it is a priority for the nurse to
notify the primary health care provider if
the client
The charge nurse observes a newly hired raising the foot of the clients bed
nurse caring for a client who sustained a
closed head
injury, is receiving mechanical ventilation,
and is at risk for developing ICP. Which of
the following
actions, if performed by the newly hired
nurse, requires intervention by the charge
nurse?
The newly hired nurse is caring for a client Clustering client care activities
who was admitted 12 hours ago with a TBI
and is at risk
for developing ICP. It requires intervention
by the nurse preceptor if the newly hired
nurse is observed
The nurse is assessing clients for the risk of 20 yr old college student who participates on the football team
sustaining TBI. Which of the following
clients should
the nurse identify as being at greatest risk?
, The nurse is caring for assigned clients. the development of asymmetric pupils with no reaction to light in the client who has
Which of the following assessment findings the TBI
requires the
nurse to notify the PHCP?
The nurse is caring for a client with a TBI Perform a halo sign test
and a skull fracture. The nurse noted that
the client had
developed rhinorrhea (nasal drip) positive
for glucose. Which of the following actions
should the
nurse take next?
The nurse is providing discharge i will bring my partner to the ED if they immediately starting vomiting
instructions to a client's partner who
sustained a mild head
injury due to an MVA. Which of the
following statements, if made by the
partners, would indicate
the need for additional teaching?
The nurse is caring for the following The client who has brain injusry and bp change from 110/58 to 134/40
assigned clients. Which client should the
nurse see first?
The nurse is caring for a client who is 24 Perform a neurological test
hours post-op following a craniotomy. The
client is
reporting a headache that is rated as an 8
on a scale of 0-10 pain scale. Which of the
following actions should the nurse take?
The nurse is caring for a client who has has a change in BP from 120/78 to 130/60
encephalitis. It is priority for the nurse to
follow up if the
client
The nurse is caring for a client who has Prepare the client for a lumbar puncture
been admitted with suspected bacterial
meningitis. Which
of the following actions should the nurse
take first?
The nurse is caring for the client who has implement seizure precautions
confusion, fever, headache, blurred vision,
NV, and a
history of HIV. Which of the following
actions should the nurse take first?
Findings: T5 SCI 6 months ago, flushed palpate the clients bladder (Autonomic dysreflexia)
face, profuse sweating, reports blurred
vision, BP 145/95,
HR 68, O2 95%. Which of the following
actions should the nurse take?
The nurse working in the ED is caring for a Mannitol
client admitted with a suspected spinal
cord injury. It
would require follow up by the nurse if the
PHCP prescribed which of the following?
The nurse is working in the emergency takes prescribed warfarin daily
department and is admitting a client who
has a sustained TBI, following a motor
vehicle crash, it is a priority for the nurse to
notify the primary health care provider if
the client
The charge nurse observes a newly hired raising the foot of the clients bed
nurse caring for a client who sustained a
closed head
injury, is receiving mechanical ventilation,
and is at risk for developing ICP. Which of
the following
actions, if performed by the newly hired
nurse, requires intervention by the charge
nurse?
The newly hired nurse is caring for a client Clustering client care activities
who was admitted 12 hours ago with a TBI
and is at risk
for developing ICP. It requires intervention
by the nurse preceptor if the newly hired
nurse is observed
The nurse is assessing clients for the risk of 20 yr old college student who participates on the football team
sustaining TBI. Which of the following
clients should
the nurse identify as being at greatest risk?
, The nurse is caring for assigned clients. the development of asymmetric pupils with no reaction to light in the client who has
Which of the following assessment findings the TBI
requires the
nurse to notify the PHCP?
The nurse is caring for a client with a TBI Perform a halo sign test
and a skull fracture. The nurse noted that
the client had
developed rhinorrhea (nasal drip) positive
for glucose. Which of the following actions
should the
nurse take next?
The nurse is providing discharge i will bring my partner to the ED if they immediately starting vomiting
instructions to a client's partner who
sustained a mild head
injury due to an MVA. Which of the
following statements, if made by the
partners, would indicate
the need for additional teaching?
The nurse is caring for the following The client who has brain injusry and bp change from 110/58 to 134/40
assigned clients. Which client should the
nurse see first?
The nurse is caring for a client who is 24 Perform a neurological test
hours post-op following a craniotomy. The
client is
reporting a headache that is rated as an 8
on a scale of 0-10 pain scale. Which of the
following actions should the nurse take?
The nurse is caring for a client who has has a change in BP from 120/78 to 130/60
encephalitis. It is priority for the nurse to
follow up if the
client
The nurse is caring for a client who has Prepare the client for a lumbar puncture
been admitted with suspected bacterial
meningitis. Which
of the following actions should the nurse
take first?
The nurse is caring for the client who has implement seizure precautions
confusion, fever, headache, blurred vision,
NV, and a
history of HIV. Which of the following
actions should the nurse take first?
Findings: T5 SCI 6 months ago, flushed palpate the clients bladder (Autonomic dysreflexia)
face, profuse sweating, reports blurred
vision, BP 145/95,
HR 68, O2 95%. Which of the following
actions should the nurse take?
The nurse working in the ED is caring for a Mannitol
client admitted with a suspected spinal
cord injury. It
would require follow up by the nurse if the
PHCP prescribed which of the following?
