NUR 265 EXAM 3 2026 ALL QUESTIONS AND CORRECT DETAILED
ANSWERS ALREADY A GRADED WITH EXPERT FEEDBACK |NEW AND
REVISED
1. The RN is working in the ED and is admitting a pt who has sustained a TBI following
a motor vehicle crash. It is priority for the RN to notify the PHCP if the pt..?: takes
prescribed warfarin daily
- Bleeding rsk from primary TBI (possible hematoma)
2. The charge RN is observing a newly hired RN care for a pt who sustained a
closed head injury, is receiving mechanical ventilation and is at risk for
Developing ICP. Which of the following actions, if preformed by the newly hired RN,
requires intervention by the charge RN?: raising the foot of the pt bed
- Should raise the HEAD, not the foot
3. The newly hired RN is caring for a pt who was admitted 12 hours ago with a TBI
and is at risk for developing ICP. It requires intervention by the RN preceptor if the
newly hired RN is observed?: clustering the pt care activities
- NEVER cluster care for these pts, it can increase ICP dramatically
4. The Rn is assessing pts for the risk of sustaining TBI. Which of the following pts
should the RN identify as being at greatest risk?: 20 year old college student who participates on the
football team
- Sport injuries : colliding with stationary object
5. The RN is caring for assigned pts. Which of the following assessement find-ings
requires the RN to notify the PHCP?: the development of asymmetric pupils with no reaction to light in a pt who
has a TBI
- Sx of ICP
6. The RN is caring for a pt who had a TBI with skull fx. The RN noted that the pt has
developed rhinorrhea that is positive for glucose. Which of the following actions should
the RN take next?: preform a halo sign test
- Determine if the nasal drainage is CSF
7. The RN is providing discharge instructions to the partner of a pt who sus-tained
a mild head injury as a result of a motor vehicle crash. Which of
1/7
, The following statements, if made by a partner, would indicate the need for additional
teaching?: if my partner is sleeping, i will wake them up every 5-6 hours
- Let them sleep
2/7
ANSWERS ALREADY A GRADED WITH EXPERT FEEDBACK |NEW AND
REVISED
1. The RN is working in the ED and is admitting a pt who has sustained a TBI following
a motor vehicle crash. It is priority for the RN to notify the PHCP if the pt..?: takes
prescribed warfarin daily
- Bleeding rsk from primary TBI (possible hematoma)
2. The charge RN is observing a newly hired RN care for a pt who sustained a
closed head injury, is receiving mechanical ventilation and is at risk for
Developing ICP. Which of the following actions, if preformed by the newly hired RN,
requires intervention by the charge RN?: raising the foot of the pt bed
- Should raise the HEAD, not the foot
3. The newly hired RN is caring for a pt who was admitted 12 hours ago with a TBI
and is at risk for developing ICP. It requires intervention by the RN preceptor if the
newly hired RN is observed?: clustering the pt care activities
- NEVER cluster care for these pts, it can increase ICP dramatically
4. The Rn is assessing pts for the risk of sustaining TBI. Which of the following pts
should the RN identify as being at greatest risk?: 20 year old college student who participates on the
football team
- Sport injuries : colliding with stationary object
5. The RN is caring for assigned pts. Which of the following assessement find-ings
requires the RN to notify the PHCP?: the development of asymmetric pupils with no reaction to light in a pt who
has a TBI
- Sx of ICP
6. The RN is caring for a pt who had a TBI with skull fx. The RN noted that the pt has
developed rhinorrhea that is positive for glucose. Which of the following actions should
the RN take next?: preform a halo sign test
- Determine if the nasal drainage is CSF
7. The RN is providing discharge instructions to the partner of a pt who sus-tained
a mild head injury as a result of a motor vehicle crash. Which of
1/7
, The following statements, if made by a partner, would indicate the need for additional
teaching?: if my partner is sleeping, i will wake them up every 5-6 hours
- Let them sleep
2/7
