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NUR 265 EXAM 3 LATEST 2025/2026 ACTUAL EXAM
WITH COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS (100% VERIFIED ANSWERS)
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RN working in ED and is admitting a pt who has TBI from MVC-- what is the priority to notify to PCP - Answer-takes warfarin daily--there could be a hemorrhage as part of the injury. warfarin is a blood thinner
Newly hired nurse caring for a pt who has a closed head injury, on a vent, at risk for ICP--what action requires intervention? - Answer-raising the foot of the pt beds-- maintain the head midline/neutral position to prevent increased ICP
new nurse w pt admitted 12 hrs. ago TBI, at risk for ICP-- what requires intervention ? - Answer-clustering pt care/activities-- cluster care= increased ICP
assessing pts for the risk of sustaining TBI, which of the following pts should the nurse identity as the greatest risk? 1 / 4
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- Answer-20 year old college student who is on the football
team.
Nurse w assigned pts. which assessment finding would need to be reported to PCP? - Answer-the development of asymmetric pupils with no reaction to light in the pt who has a TBI-- pupillary changes;
nurse caring for a pt who had a TBI w skull fx. the nurse noted that the pt has rhinorrhea and it is positive for glucose--what action is next? - Answer-perform a halo sign test--CSG leaking, lab test will be analyzed for glucose and electrolyte content. place fluid on a while absorbent paper/linen
nurse providing dc teaching to pts partner who sustained a mild head injury from MVC. --what statement requires additional teaching? - Answer-I will bring my partner to the ED if they immediately start vomiting--symptoms usually resolve within 72 hrs NV is expected.
Nurse is caring for the following pt. which pt would the nurse see first? - Answer-the pt who has a brain injury and 2 / 4
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a BP change from 110/58 to 134/40-- cushings triad.severe htn, widening pulse pressure, bradycardia
24 hr post op craniotomy. pt is reporting headach 8/10-- what is the next step for the nurse to take? - Answer- perform a neuro assessment--minimize ICP, assess the problem.
sx of increased ICP= headache, deteriorating LOC, restlessness and irritability.
pt with encephalitis. what is the priority for the nurse to f/u on? - Answer-has a change in BP from 120/78 to 130/60-- changes in vs that require immediate notification to HCP are a widened pulse pressure, new bradycardia and irregular respiratory effort.
nurse caring for a pt who has been admitted with suspected bacterial meningitis. which action should the nurse take first? - Answer-Droplet precautions. prepare the client for a lumbar puncture--most important test.
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pt has confusion, fever, headache, blurred vision, NV, hx of HIV- what should the nurse do FIRST? - Answer- implement seizure precautions-- pt could have encephalitits dues to HIV/fever, seizures are common
T5 SCI 6 months ago. s/s flushed face, profuse sweating, blurred vision, bp 145/95 hr68 95%--what should the nurse do first? - Answer-palpate the bladder--catheterize the pt with autonomic dysreflexia to decrease the pressure.EMERGENT. severe htn. elevate HOB
pt admittd with SCI. what prescription would require f/u? - Answer-mannitol- used to tx ICP dextran, atropine, dopamine are used for SCI
Dextran - Answer-increased cap blood flow to tx hypotension
atropine - Answer-tx reduce HR
Dopamine - Answer-tx of hypotension nurse is assessing a client who has GB. Nurse notes diminished lung sounds, RR 8 shallow, pulse ox 88%--
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