NUR 265 EXAM 3 REVIEW 2026 – COMPREHENSIVE NURSING
STUDY GUIDE & PRACTICE QUESTIONS
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? - 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 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.
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
STUDY GUIDE & PRACTICE QUESTIONS
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? - 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 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.
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
