Nur 265 exam 3 questions with answers galen college of nursing guaranteed pass A+ Grade

#1:The nurseisworkingintheemergencydepartment(ED)isadmittingaclientwhohassustaineda
x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




traumaticbraininjury(TBI)followingamotorvehiclecrash.Itispriorityforthenursetonotifytheprimary
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




healthcare provider (PHCP) in the client:
x3 x3 x3 x3 x3 x3




Takes prescribed warfarin daily. x3 x3 x3




RATIONALE: Pg. 2400. Hemorrhage may occur as part of the primary injury and begin at the moment of x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 y x3 x3 x 3




impact. Warfarin is a blood thinner and the patient may bleed out if they have a hematoma (a collection of
x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x 3 x3




blood)
x3




#2:The chargenurseis observinganewlyhirednursecareforaclientwhosustainedaclosedheadinjury, is
x3 y x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




receivingmechanicalventilation,andisat risk for developingICP.Whichofthefollowing actions,if
x3 x3 x3 x3 x3 x3 y x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3




performed by thenewly hirednurse, requires interventionby the chargenurse?
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




Raisingthefootoftheclient’sbed. ,yr




RATIONALE: Pg. 2413. Maintain the head midline, neutral position to prevent increased ICP. x3 x3 x3 x3 x3 x3 x3 x3 x3 y x 3 x3




#3:Thenewlyhirednurseiscaringforaclient whowasadmitted12hoursagowithaTBIandisat risk for
x3 x3 x3 x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 y x3 y x3




developing ICP. It requires intervention by the nurse preceptor if the newly hired
x3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3




nurse is observed
x 3 x 3 x3




Clustering client care activities x3 x3 x 3




RATIONALE:pg.2387.Whenmultiple activitiesareclusteredinarow,theeffectonICPcanbedramatic x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




elevation.
x3




#4:Thenurseisassessingclientsfortherisk ofsustainingTBI.Whichofthefollowingclientsshouldthe nurse
x3 x3 x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




identify asbeing at greatest risk?
x3 x3 x3 y x3




20yearoldcollegestudentwhoparticipatesonthefootballteam.
RATIONALE: Pg. 2397. A force produce by a blow direct to the head can contribute to a brain injury. x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




#5:The nurseiscaringforassignedclients.Whichofthefollowingassessment findingsrequiresthenurse to
x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3




notify the PHCP?
x3 x3 x3




The development of asymmetric pupils withnoreaction tolightinthe client who has a TBI.
y x3 y x3 x3 y x3 x3 y x3 y x3 y x3,r x3 y x3 x3




x RATIONALE:Pg.2386.Pupillarychanges;dilatedandnonreactivepupils“blown”orconstrictive,non
3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




reactivepupils.
x3 x3




#6:ThenurseiscaringforaclientwhohadaTBIwithskullfracture.Thenursenotedthattheclienthas
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




developedrhinorrhea(nasaldrip)that ispositiveforglucose.Whichofthefollowingactionsshouldthe
x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




nursetake next? x3 x3




Perform a halo sign test. x3 x3 x3 x3




RATIONALE:Pg.2410.CSFleaking,labtestwillbeanalyzedforglucose andelectrolytecontent.Placeona white x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




absorbent paper or linen.
x3 y x3 x3 x3




#7:Thenurseisprovidingdischargeinstructionstothepartnerofaclientwhosustainedamildhead injury asa
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x 3 x 3 x3 x3




result ofaMVA.Whichofthefollowingstatements,ifmadebythepartnerswouldindicated
x3 y x3 x3 x3 theneed for x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x 3 x 3 x3 x3




additionalteaching?
x3 x3




I will bring my partner to the ED if they immediately starting vomiting.
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




RATIONALE:Pg. 2405. Symptoms usually resolve within72 hrs. NV expected.
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




#8: The nurse is caring for the following assigned clients. Which client should the nurse see first?
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The client who has a brain injury and a BP change from 110/58 to 134/40 mm Hg.
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RATIONALE: Pg. 2386.Cushing Triad. Severe HTN, widened pulse pressure, bradycardia.
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




#9: The nurse is caring for a client who is 24 hours post op following a
x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3




xcraniotomy. The client isreportingaheadache that isratedasan8onascaleof0-10painscale.Whichof
3 x 3 x 3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




thefollowingactions should the nurse take?
x3 x3 x3 x3 x3 x3 x3

, Perform a neurological test. x3 x3 x3




RATIONALE:Pg.2430.SymptomsofincreasedICPincludedserversheadache,deterioratingLOC, x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




restlessness, andirritability.
x3 x3 x3




#10:Thenurseiscaringforaclient whohasencephalitis.Itispriorityforthenursetofollowupiftheclient Has a
x3 x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




change in BP from 120/78 to 130/60 mm Hg.
x3 x3 x3 x3 x3 x3 x3 x3 x3




RATIONALE:Pg.2256.ChangesinVSthatrequireimmediatenotificationto theHCPareawidenedpulse x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3




pressure, newbradycardia, and irregular respiratory effort.
x3 x3 x3 x3 x3 x3




#11:Thenurseiscaringforaclient whohasbeenadmittedwithsuspectedbacterialmeningitis.Which of
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the following actions should the nurse take first?
x3 x3 x3 x3 x3 x3 x3 x3




Prepare the client for a lumbar puncture. x3 x3 x3 x3 x3 x3




RATIONALE:Pg.2251.Most significant labtest todetermineBMistestingofCSFwithalumbarpuncture. A x3 x3 x3 y x3 y x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




broadx spectrum
3 antibiotic is given before the lumbar puncture.
x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3




#12:Thenurseiscaringfortheclientwhohasconfusion,fever,headache,blurredvision,NV,andahistory of
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




HIV. Which of the following actions shouldthenursetake first?
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




Implement seizure precautions. y x 3 x3




RATIONALE:Thispatient couldhaveencephalitisduetothehxofHIVandfever.Seizureactivityis common. x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




#13:Findings:T5SCI6monthsago,flushedface,profusesweating,reportsblurredvision,BP145/95,HR68, O2
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 y




95%. Which ofthe following actions should the nursetake?
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




Palpate the patient’s bladder. x 3 x 3 x 3




RATIONALE:Catheterizethepatientwithautonomic dysreflexiatodecreasethepressure.This isan x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 y x3 x3




emergency. Immediately elevated the HOB.
x3 x3 x3 x3 x3




#14:Thenurseworkingi ntheEDisc aringforaclientadmittedwithas uspectedspinalcordinjury.It ,ry x 3 y, r x 3 , x 3




would requirefollowupbythenurse ifthePHCPprescribedwhichofthe following?
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




Mannitol.
RATIONALE:Pg.2291.Mannitolisusedtotreat ICP.Dextran,Atropinesulfate,andDopamineareusedto x3 x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3




treat SCI.
x3 y x3




#15: The nurse has taught a client who hasmyasthenia gravis about taking their prescribed medications
x3 x3 x3 x3 y x 3 x3 x3 x3 x3 x3 y x3 x3 x3




on time and 45-60 mins prior to meals. The client asks why timing is so important. Which ofthefollowing
x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 y x 3 x3 x3 x3 x3 x3 x3 x3 x3




is an appropriate response by the nurse?
x3 x3 x3 x3 x3 x3 x3




Thisallowst hemedicationtohavemaximumeffect,soiti seasierforyoutoc hewandswallow. y,r x 3 ,yr ,ry x 3 y,r x 3




RATIONALE: Pg. 2344. Drug Alert! Eat 45-60 mins prior to avoid aspiration. x3 x3 x3 x3 x3 x3 x3 x3 y x3 ,r x3 y x3 , x 3 x3




#16: The nurse is working in the ED is caring for a client who has MG. The client presents with muscle
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 y x 3 x3 x3




weakness,NVD,andpulseof58.Whichofthefollowingmedicationsshouldthenurseadminimmediately?
x 3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




Atropine sulfate. x 3




RATIONALE: Pg. 2345. In choliner gic crisis, admin Atropine I mg IV. x3 x3 x3 x3 x3 x3 x3 x3 x3




#17:ThenursepreceptorisobservinganewlyhirednursecareforaclientwhohasMG.Whichofthefollowing
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




actions by the newly hired nurse requires immediate intervention by the
x3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3




nurse preceptor?
x 3 x 3




Preparing to admin a prescribed PRN laxative. x3 x3 x3 x3 x3 x3




RATIONALE:Pg.2346.Performtasksduringpeakmedicationtimes,monitorserumalbuminlevels,and x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




providehigh calorie snacks.
x3 x3 x3 x3




#18: The nurse is teaching a client who has recently diagnosed with trigeminal neuralgia. Which of the
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3

, followings tatementsbythec lientwouldindicateneedforfurtherteaching? y,r x 3 y,r x 3 ,ry




Iwilltapemyaffectedeyec losedatbedtime. ,ry y,r x 3 x 3




RATIONALE: Pg. 2354. Seizure medication is first choice drug, facial twitching or spasms may occur, pain x3 x3 x3 x3 x3 x3 y x 3 x3 x3 x3 x3 x3 x3 x3 x3




is usually provoked byminimal stimulation of a trigger zone (such asdenture procedures.) Taping of the
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x 3 x3




eye is not necessary for this patient.
x3 x3 x3 y x3 x3 x3 x3




#19:Thenurseisprovidedteachingtoac lientwhowasjustdiagnosedwithBell’spalsy.Whichofthe y,r x 3 ,ry ,yr ,ry ,




following client statements requires follow up by the nurse?
x3 x3 x3 y x 3 x3 x3 x3 x3 x3




I will need to take carbamazepine to control my symptoms.
x3 x3 x3 x3 x3 x 3 x3 x3 x 3




RATIONALE:Pg.2255.ThismedicationisusedtotreatTN.Patientswilltakesteroids,useheattocontrol x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




pain, and mayexperience ringing of the ears.
x3 x3 x3 x3 x3 x3 x3




#20:Thenurseiscaringforthefollowingassignedclients.It wouldbeappropriateforthenurseto recommenda
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3




referralfor evaluation for palliative care for the client who
x3 x3 x3 x3 x3 x3 x3 x3 x3 y x3




HashadALSforthepast 3yearsandwas recentlyadmittedwithpain,fatigue,anddifficultybreathing.
x3 x3 x3 x3 x3 y x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3




RATIONALE:Pg.2268.ALSisachronicne urological disease that causesprogressive muscleweakness x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




andwasting,leadingtoparalysisofrespirat orymuscles.
x3 x3 x3 x3 x3 x3 x3




#21:ThenurseisdiscussingadvanceddirectiveswithaclientwhohasALS.Theclienttellsthenurse“I don’t
x3 x3 x3 x3 x3 x3 x3




wanttobeputonabreathingmachine.”Whichofthefollowingisanappropriateresponsebythenurse?
x3 ,yr ,yr ,yr x3




What would you like to be done if you start to have difficulty breathing? x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




RATIONALE:Involvet heclientintheircare,askwhatt hey’dliketohappen. y,r x 3 , y,r x 3 ,




x 3 x 3




#22:ThenursehasattendedaCE conferenceonGB.Whichofthefollowingstatementsbythenurse
x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




indicates a correct understanding of the conference?
x3 x3 x3 y x 3 x3 x3 x3




The immune system reacts by destroying the myelin sheath. x3 x3 x3 x3 x3 x3 x3 x3




RATIONALE:Pg.2329.Primarilytheaxonsareaffected.Inotherforms,demyelinationtypicallybegininthe legs x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




and spread to the armsand upper body.
x3 x3 x3 x3 x3 x3 x3




#23:ThenurseisassessingaclientwhohasGB.Thenursenotes diminishedlungsounds,respirationsof 8 and
x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3 x3 x 3 x3




shallow, and a pulse ox of 88%. Which of the following actions should the
x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3




nurse take?
x 3 x 3




Prepare the client for intubation. x3 x3 x3 x3




RATIONALE:PG.2334.Theprioritynursinginterventionofairwaymanagement istopromoteairway x3 x3 x3 x3 x3 x3 x3 x3 x3 y x3 x3 x3 x3




latency and adequate gas exchange.
x3 x3 x3 x3 x3




#24: The nurse is using the rule of 9s to calculate the extent of a clients burn
x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3 x 3




injury. The client has burns to the posterior area of the torso, arms, and legs. The nurse should
x 3 x 3 x 3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3 x3




document that the percent of the body surface burned is:
x3 y x3 y x 3 x3 y x 3 x3 x3 x3 x3 x3




45% 18+4.5+4.5+9+9=45
RATIONALE:Pg.1302.
Ruleof9sforestimatingburnpercentage.Head
x3 x3 x3 x3 x3 x3 x3




A&P:4.5%,4.5%
x3 x3 x3




Arms A&P: 4.5%, 4.5% x3 x3 x3




Torso A&P: 18%, 18% x3 x3 x3




Genitals: 1% x3




Legs A&P: 9%, 9% x3 x3 x3