NU265 / NU 265 Exam 3: Med Surg Literally Questions and Answers | Latest Updated 100% 2025/26.

NU 265 Exam 4 Actual Questions and Answers Updated 2025/26 – Galen. #1: The nurse is working in the emergency department (ED) is admitting a client who has sustained a traumatic brain injury (TBI) following a motor vehicle crash. It is priority for the nurse to notify the primary healthcare provider (PHCP) in the client: #2: The charge nurse is observing a newly hired nurse care 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? #3: The newly hired nurse is caring for a client 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 #4: The nurse is assessing clients for the risk of sustaining TBI. Which of the following clients should the nurse identify as being at greatest risk? #5: The nurse is caring for assigned clients. Which of the following assessment findings requires the nurse to notify the PHCP? #6: The nurse is caring for a client who had a TBI with skull fracture. The nurse noted that the client has developed rhinorrhea (nasal drip) that is positive for glucose. Which of the following actions should the nurse take next? #7: The nurse is providing discharge instructions to the partner of a client who sustained a mild head injury as a result of a MVA. Which of the following statements, if made by the partners would indicated the need for additional teaching? #8: The nurse is caring for the following assigned clients. Which client should the nurse see first? #9: The nurse is caring for a client who is 24 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? #10: The nurse is caring for a client who has encephalitis. It is priority for the nurse to follow up if the client pulse pressure, new bradycardia, and irregular respiratory effort. #11: The nurse is caring for a client who has been admitted with suspected bacterial meningitis. Which of the following actions should the nurse take first? #12: The nurse is caring for the client who has confusion, fever, headache, blurred vision, NV, and a history of HIV. Which of the following actions should the nurse take first? #13: Findings: T5 SCI 6 months ago, flushed face, profuse sweating, reports blurred vision, BP 145/95, HR 68, O2 95%. Which of the following actions should the nurse take? #14: The nurse working in the ED is caring for a client admitted with a suspected spinal cord injury. It would require follow up by the nurse if the PHCP prescribed which of the following? #15: The nurse has taught a client who has myasthenia gravis about taking their prescribed medications on time and 45-60 mins prior to meals. The client asks why timing is so important. Which of the following is an appropriate response by the nurse? #16: The nurse is working in the ED is caring for a client who has MG. The client presents with muscle weakness, NVD, and pulse of 58. Which of the following medications should the nurse admin immediately? #17: The nurse preceptor is observing a newly hired nurse care for a client who has MG. Which of the following actions by the newly hired nurse requires immediate intervention by the nurse preceptor? #18: The nurse is teaching a client who has recently diagnosed with trigeminal neuralgia. Which of the following statements by the client would indicate need for further teaching? I will tape my affected eye closed at bedtime. #19: The nurse is provided teaching to a client who was just diagnosed with Bell’s palsy. Which of the following client statements requires follow up by the nurse? #20: The nurse is caring for the following assigned clients. It would be appropriate for the nurse to recommend a referral for evaluation for palliative care for the client who Has had ALS for the past 3 years and was recently admitted with pain, fatigue, and difficulty breathing. #21: The nurse is discussing advanced directives with a client who has ALS. The client tells the nurse “I don’t want to be put on a breathing machine.” Which of the following is an appropriate response by the nurse? #22: The nurse has attended a CE conference on GB. Which of the following statements by the nurse indicates a correct understanding of the conference? #23: The nurse is assessing a client who has GB. The nurse notes diminished lung sounds, respirations of 8 and shallow, and a pulse ox of 88%. Which of the following actions should the nurse take? #24: The nurse is using the rule of 9s to calculate the extent of a clients burn injury. The client has burns to the posterior area of the torso, arms, and legs. The nurse should document that the percent of the body surface burned is: #25: The nurse is caring for a male client who sustained full thickness burns on the back and posterior legs six hours ago. Which of the following lab values would be an initial expected finding? #26: The nurse is caring for a client who is burned and has developed drooling and difficulty swallowing. Which of the following actions should the nurse first take? Auscultate breath sounds over the trachea and mainstream bronchi. #27: The nurse is caring for a client who sustained an electrical injury and was brought to the ED. Which of the following nursing actions should the nurse take first? #28: The nurse is caring for a client who suffered 33% TBSA 48hr ago. The nurse notes a gradual increase in the client’s urine output over the last 12 hrs. Which of the following actions would the nurse take? #29: The nurse working in the ED is caring for a client with full thickness burns to 25% of the TSBA. After ensuring cardiopulmonary stability, which of the following actions should the nurse take next? #30: The nurse working in the burn unit is caring for a client who suffered burn injuries 48 hrs ago and has been receiving resuscitation. The client has been stable but is now experiencing a change in respiratory status. Which of the following should the nurse correlate to this change in the client’s status? #31: The nurse preceptor is observing a newly hired nurse who is caring for assigned clients in a burn unit. It would require follow up by the preceptor if the newly hired nurse: #32: The nurse has taught a client with facial burns about wearing the facial pressure garment. Which of the following client statements indicates understanding of the teaching? #33: The nurse working on the burn step down unit has become aware of the following situations. The nurse should initially follow up with the client who has: #34: The nurse is admitting a client who has sustained a therm burn injury. The nurse notes the following assessment findings. HR 140, RR 25, BP 70/40, Skin pale, faint pedal pulses. Which of the following actions should the nurse take first? #35: The nurse is caring for a client who has circumferential full thickness burns to the left lower extremity. Which of the following findings of the affected extremity requires immediate follow up by the nurse? #36: The nursing is caring for a client who was admitted 12 hr ago with severe burns. The client is receiving fluid resuscitation and weighs 175 lbs (79.5 kg). Which assessment findings is a priority for the nurse to report to PHCP? #37: The nurse working the ED is assessing a client who presents with clinical manifestations of shock. Which of the following manifestations indicates that the client’s shock is caused by sepsis (infection)? #38: The nurse is caring for a client who is not responding to interventions for treatment of shock. Which of the following actions should the nurse include during this phase of the client’s care? Communicate clearly and frequently with the client’s family. #39: The nurse is admitting a client diagnosed with septic shock. Which of the following interventions should the nurse perform next? #40: The nurse is caring for a client who has severe septic shock. Which of the following prescriptions should the nurse question? #41: The nurse is caring for a client who has developed hypovolemic shock due to blood loss during surgery. The nurse should place the client in with of the following positions? #42: The nurse is monitoring a client who is receiving dopamine infusion for treatment of hypovolemic shock. Which of the following indicates a therapeutic response to the medication? #43: The nurse is caring for a client who has developed hypovolemic shock resulting from dehydration due to several days of VD. Which of the following actions should the nurse take next? #44: The nurse should recognize the development of obstructive shock in the client who: #45: The nurse is caring for a client who is in cardiogenic shock and has been prescribed continuous infusion of norepinephrine. The nurse should recognize that the therapeutic effect of this medication: #46: The nurse is caring for a client who is in cardiogenic shock, was starting on a continuous infusion of an inotrope and has received a diuretic. It is a priority for the nurse to notify the PHCP if the client: #47: The nurse is caring for a client who has been prescribed continuous infusion of dopamine at a rate of 5 mcg/kg/min. The pharmacy has provided a solution of dopamine 400 mg in 250 mL D5W. The client weighs 198 lbs. which of the following actions should the nurse take? 5 mcg/kg/min x 60 =1hr 5 mcg x 90 kg x 60 0.005 mg x 90 kg = 0.45 x 60 = 27 mg 250 mL X 27 mg = 16. 875 = 16.9 mL/hr 400 mg Test 3 Read the questions carefully it could change 1. The nurse is working in the ED is admitting a client who has sustained a TBI following a motor vehicle crash. It is a priority for the nurse to notify the PHCP if the client a. Takes a prescribed warfarin daily b. Is unable to remember the crash c. Reports having a continuous HA d. Has a BP of 162/94 2. The nurse is observing a newly hired nurse care 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? a. Using the bag-valve-mask on the client when the low-pressure alarm sounds b. Maintaining the client’s head at midline, neutral position c. Setting up suction equipment at the bedside d. Raising the foot of the client’s bed 3. The newly hired nurse is caring for a client 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 a. Checking the client’s vital signs every hour b. Clustering client care activities c. Instructing the client not to assist during repositioning d. Encouraging the client’s visitors not to stimulate the client 4. The nurse is assessing clients for the risk of sustaining a TBI. Which of the following clients should the nurse identify as being at greatest risk? a. 45-year-old who has epilepsy and takes prescribed phenytoin b. 7-yar-old who is learning how to ride a bike without training wheels c. 20-yar-old college student who participates on the football team d. 60-yar-old who lives alone and wears a hearing aid 5. The nurse is caring for assigned clients. Which of the following assessment findings requires the nurse to notify the PHCP? a. An output of 30 ml from the surgical drain of a client who had a craniotomy 6 hrs ago b. A report of tinnitus by a client who was recently diagnosed with an acoustic neuroma c. The development of asymmetric pupils with no reaction to light in a client who has a TBI d. A decrease in the Glasgow coma scale score from 4 to 3 in a client who has a brain tumor 6. Then nurse us caring for a client who had a TBI with skull fracture. The nurse notes that the client has developed rhinorrhea that is positive for glucose. Which of the following actions should the nurse take next? a. Apply a drip pad to the client’s nose b. Prepare to suction the client c. Perform a halo sign test d. Notify the PHCP 7. The nurse is assessing a client who has experienced a mild TBI. Which of the following findings is consistent with this diagnosis? a. Difficulty concentrating b. A Glasgow coma scale score of 11 c. Constricted pupils that are nonreactive to light d. Hand tremors 8. Then nurse is providing discharge instructions to the partner of a client who sustained a mild head injury as a result of a motor vehicle crash. Which of the following statements by a partner indicates a correct understanding of the teaching? a. I will bring my partner to the ED immediately if they begin to vomit b. It is expected that my partner will have drainage from the nose for the next few days c. If my partner is sleeping I will wake them up every 5-6 hours d. I will give my partner a lorazepam tonight to help with anxiety 9. The nurse is caring for a client who is 24 hours postoperative following a craniotomy. The client is reporting a HA that is rated as an 8 on a 0 to 10 pain scale. Which of the following actions should the nurse take? a. Apply a heat pack to the back of the client’s neck b. Place the client in a side-lying position c. Reposition the client supine with a pillow under the knees d. Perform a neurological assessment 10. The nurse is caring for the following assigned clients. Which client should the nurse see first? a. The client who has a skull fracture, is alert and oriented, and reports feeling nauseated b. The client who has meningitis, is irritable, and reporting a HA c. The client who has encephalitis and development of myoclonic jerking and tremors d. The client who has a brain injury and unable to remember the events surrounding the injury 11. The nurse is caring for a client who has encephalitis. It is a priority for the nurse to notify the PHCP if the client develops a. A HA b. Fatigue c. Increased sensitivity to noise d. Decreased pulse rate 12. The nurse working in the ED is caring for a client who presents with suspected bacterial meningitis. After performing a neuro assessment, which of the following actions should the nurse anticipate taking next? a. Placing the client in a negative pressure room b. Teaching the client about the condition and treatment c. Preparing the client for a lumbar puncture d. Admin an antiepileptic medication 13. The nurse is caring for a client who has confusion, fever, HA, blurred vision, nausea, vomiting, and a history of HIV. The client is diagnosed with H. influenzae meningitis. Which of the following actions should the nurse take first? a. Initiate standard and droplet precautions b. Obtain a blood specimen for CBC count c. Insert an IV catheter d. Prepare the client for a CT scan 14. The nurse is caring for a client who has the following history and assessment findings: T5 spinal card injury 6 months ago, flushed face, profuse sweating, reports blurred vision, BP 184/95, pulse 68, pulse ox 95%. Which of the following actions should the nure take first? a. Palpate the client’s bladder b. Prepare the admin an enema c. Adjust the room temp to comfort d. Assess the skin for pressure injury 15. The nurse working in the ED is caring for a client admitted with a suspected SCI. which of the following medications should the nurse plan to have readily available? a. Interferon b. Atropine sulfate c. Mannitol d. Pyridostigmine 16. The nurse working in a rehab unit is caring for a client who had a SCI that resulted in paraplegia. The nurse notes that the client has become withdrawn and increasingly resistant to participate in rehab activities. Which of the following actions should the nurse take? a. Allow the client to control the timing and frequency of the therapy sessions b. Limit visiting hours so the client can focus better on therapy activities c. Establish a plan of care with the client that sets attainable goals d. Obtain a prescription for a neurological consultation 17. The nurse has taught a client who has myasthenia gravis about taking their prescribed medications on time and 45-60 minutes prior to meals. The client asks why the timing is so important. Which of the following is an appropriate response by the nurse? a. Many clients find it easier to remember to take their medications if they associate it with mealtimes b. The medication needs to be taken on an empty stomach for max absorption and effect c. Many foods interact with your medications and this timing will allow them to absorb without causing problems d. This allows the medication to have max effect, so it is easier for you to chew and swallow 18. The nurse working in the ED is caring for a client who has myasthenia gravis. The client presents with bladder incontinence, dysphagia, absence of cough, respirations of 40 with dyspnea, and generalized weakness. Which of the following actions should the nurse take immediately? a. Gather intubation equipment b. Set up bedside suction c. Admin atropine sulfate d. Insert an indwelling urethral catheter 19. The nurse preceptor is observing a newly hired nurse care for a client who has myasthenia gravis. Which of the following actions by the newly hired nurse requires immediate intervention by the nurse preceptor? a. Monitoring the client’s weight and prealbumin blood levels b. Coordinating physical therapy treatment during peak medication times c. Preparing to admin a prescribed PRN laxative d. Providing the client with a high-calorie afternoon snack 20. The nurse is teaching a client who was recently diagnosed with trigeminal neuralgia. Which of the following statements by the client would indicate a need for further teaching? a. I will need to use a soft toothbrush when brushing my teeth b. I may notice the development of facial twitching c. I will tape my affected eye closed at bedtime d. I may need to take a seizure medication for treatment 21. The nurse has provided teaching to a client who was just diagnosed with Bell’s palsy. Which of following client statements indicates a correct understanding of the teaching? a. I may have shooting pain in my face during an attack b. I may use a cool rag or ice packs to help control pain c. I will need to take carbamazepine to control my symptoms d. I will need to take corticosteroids for a week 22. The nurse us caring for the following assigned clients. It would be appropriate for the nurse to recommend a referral for an evaluation for palliative care for the client who a. Has had ALS for the past three years and was recently readmitted with pain, fatigue, and difficulty breathing b. Has GBS, developed paralysis form the neck to the toes, and was recently placed on mechanical ventilation? c. Was recently diagnosed with encephalitis, has ICP, and has decreased LOC d. Sustained a SCI is wearing a halo fixator device, and is experiencing depression since the injury 23. The nurse us discussing advance directives with a client who has ALS. The client tells the nurse, “I don’t want to be put on a breathing machine.” Which of the following is an appropriate response by the nurse? a. What would you like done if you start to have trouble breathing b. Why are you afraid of being put on a breathing machine c. You could only be on the breathing machine for a short period of time d. You should discuss your wishes with your family and doctor 24. The nurse has attended a continuing education conference about GBS. Which of the following statements by the nurse indicates a correct understanding of the conference? a. The immune system reacts by destroying the myelin sheath b. The distal nerves degenerate and results in muscle weakness c. Antibodies develop and attach to acetylcholine receptors d. Nerve impulses are not transmitted to the skeletal muscle 25. The nurse preceptor is observing a newly hired nurses care for a client who GBS. Which of the following actions by the newly hired nurse requires intervention by the nurse preceptor? a. Assessing for dysphagia prior to eating a meal b. Admin high-flow oxygen via mask c. Setting up bedside suction equipment d. Having the client use the incentive spirometer 26. The nurse is using the Rule of Nines to calculate the extent of a male client’s burn injury. The client has burns to the entire circumference of both legs and the genitalia. The nurse should document that the percent of total body surface burned is a. 19% b. 27% c. 45% d. 28% 27. *MISSED* 28. The nurse us caring for a client who is burned and has developed drooling and difficulty swallowing. Which of the following actions should the nurse take first? a. Place the client on a continuous pulse ox meter b. Set up oxygen at the bedside for delivery via nasal cannula as needed c. Auscultate breath sounds over the trachea and mainstem bronchi d. Have ABG levels drawn on the client 29. The nurse us caring for a client who suffered burns to 33% total body surface area 48 hrs ago. The nurse notes a gradual increase in the client’s urine output over the last 12 hrs. which of the following actions should the nurse take? a. Report the findings to the PHCP b. Obtain an order to have the IV fluid rate decreased c. Gradually start increasing the client’s fluid intake d. Document the findings and continue to monitor the output 30. The nurse is caring for a client who sustained an electrical injury and was brought to the ED. After placing the client on a continuous cardiac monitor, which of the following nursing actions should the nurse take next? a. Assess the client for pain at contact points b. Apply sterile dressings to the wounds c. Initiate oxygen at 2 L via nasal cannula d. Check the client’s potassium level 31. The nurse working in the ED is caring for a client with full-thickness burns to 25% of the total body surface. After ensuring cardiopulmonary stability and initiating IV fluids, which of the following actions should the nurse take next? a. Assess the client for musculoskeletal and mobility problems b. Insert a NG tube to remove gastric sections c. Consult with the dietitian regarding nutritional needs of the client d. Obtain a prescription for psychiatric consult to address image concerns 32. The nurse working in the burn unit is caring for a client who suffered burn injuries 48 hrs ago and has been receiving resuscitation. The client has been stable but is now experiencing a change in respiratory status. Which of the following should the nurse correlate to this change in the client’s status? a. The client is staring to experience early signs of systemic infections b. This is due to prolonged exposure to carbon monoxide c. The client is having a panic attack and hyperventilating d. This is a delayed onset of respiratory complications due to fluid resuscitation 33. The nurse preceptor is observing a newly hired nurse who is caring for assigned clients in a burn unit. Which of the following actions by the newly hired nurse indicates to the preceptor correct client care? a. Applying an enzymatic debridement agent to black eschar tissue b. Informing the client that a homograft is generally obtained from pig’s skin c. Admin a prescribed opioid analgesic by mouth 20 min prior to changing the client’s dressing d. Informing the client that compression garments are worn over the dressings for a minimum of 16 hrs per day 34. The nurse has taught a client with facial burns about wearing the facial pressure garment. Which of the following client statements indicates a need for further teaching? a. I will need to wear the mask for 12-24 months b. The mask needs to be worn for 23 hrs every day c. Wearing the mask will provide protection and prevent infection d. My scars should be less severe with the use of the mask 35. The nurse working on the burn step-down unit has become aware of the following client situations. The nurse should initially follow up with the client who has a. An allergy to penicillin and has been prescribed the topical cream gentamicin sulfate b. Refused to look at the wound during the dressing changes c. Increased burn wound drainage that has developed an odor d. Reported pain while performing active range-of0motion exercises 36. The nurse is admitting a client who has sustained a thermal burn injury. The nurse notes the following assessment findings: pulse 140, respiration 25, BP 70/40, skin color pale, pedal pulses faint. Which of the following actions should the nurse take first? a. Initiate prescribed IV fluid resuscitation b. Check pedal pulses with a venous doppler device c. Obtain a 12-lead ECG d. Collet a STAT CBC 37. The nurse is caring for a client who has circumferential full-thickness burns to the left lower extremity. Which of the following findings of the affected extremity requires immediate follow up by the nurse? a. An increase in skin temp form cool to warm b. A change in skin color form pale to bright red c. An increase in the cap refill from 2 to 3 sec d. Numbness and tingling of the foot 38. The nurse us caring for a client who was admitted 12 hrs ago with severe burns. The client is receiving fluid resuscitation and weighs 175 lbs (79.5 kg). Which assessment finding(s) from the box below is a priority for the nurse to report to the PHCP? 1. Urine output of 30 ml/hr 2. BUN of 20mg/dl 3. Sodium level of 136 4. Potassium level of 6.2 5. 2+ peripheral edema 6. Dyspnea with stridor a. 3, 4, 5 b. 2, 3, 4, 6 c. 1, 2, 3, 5 d. 1, 4, 6 39. The nurse working in the ED is assessing a client who presents with a clinical manifestation of shock. Which of the following manifestations indicates that the client’s shock is caused by sepsis? a. Anxiety and confusion b. Hypotension c. Pale clammy skin d. Temp of 96.4 F 40. The nurse is caring for a client who is not responding to intervention for treatment of shock and moving into the irreversible stage of shock. Which of the following actions should the nurse include during the phase of the client’s care? a. Transfer the client to a subacute unite when recovery appears unlikely b. Begin to slowly reduce interventions as the prognosis worsens c. Communicate clearly and frequently with the client’s family d. Ask the client’s family how they would prefer treatment to proceed 41. The nurse is admitting a client diagnosed with septic shock. Which of the following interventions should the nurse perform first? a. Obtain central venous pressure measurements b. Obtain 2 sets of blood cultures c. Determine current blood glucose level d. Admin IV vancomycin 42. The nurse is caring for a client who has severe sepsis with septic shock. Which of the following prescriptions should the nurse question? a. Reg insulin IV infusion per protocol b. Cefazolin 1 g IV every 6 hrs c. Enoxaparin 40 mg subq BID d. Transfusion of 2 units of fresh frozen plasma 43. The nurse is caring for a client who has developed hypovolemic shock due to blood loss during surgery. The nurse should place the client in which of the following positions? a. Supine with head and feet flat b. HOB flat with the feet elevated c. HOB elevated 45 degrees d. Side-lying with HOB elevated 15 degrees 44. The nurse is monitoring a client who is receiving a dopamine infusion for treatment of hypovolemic shock. Which of the following indicates a therapeutic response to the medication? a. A BP that has decreased from 150/92 to 130/88 b. A pulse rate that has increased from 62 to 78 c. Urine output that has increased from 20 to 50 ml/hr d. A decreased in mean arterial pressure 45. The nurse is caring for a client who has developed hypovolemic shock resulting from dehydration due to several days of vomiting and diarrhea. Which of the following actions should the nurse take next? a. Insert indwelling urethral cath b. Admin a antiemetic med c. Start dobutamine IV by continuous infusion d. Initiate a 0.9% sodium chloride (NaCl) infusion 46. The nurse is caring for assigned clients. The nurse should recognize the development of obstructive shock in the client who a. Sustained 60% total body surface burns and has developed generalized edema b. Was admitted with an anaphylactic reaction to a newly prescribed antibiotic c. Has left-sided heart failure resulting in pulmonary hypertension d. Is bleeding from the groin after accidently being shot with a nail gun 47. The nurse is caring for a client who is in cardiogenic shock and has prescribed a continuous infusion of norepinephrine. The nurse should recognize that the therapeutic effect of the medication is to a. Decrease the client’s respiration b. Increase the mean arterial pressure c. Increase the pulse ox saturation d. Decrease the client’s apical pulse 48. The nurse us caring for a client who is in cardiogenic shock, was started on a continuous infusion of an inotrope, and received a diuretic. It is priority for the nurse to notify the PHCP if the client a. Reports the development of chest discomfort b. Has an increase in urine output from 30 to 100 ml/hr c. Reports feeling cold and requests an extra blanket d. Has an increase of 10 mm Hg in the mean arterial pressure 49. The nurse is caring for a client who has been prescribed a continuous infusion of dopamine at a rate pf 5 mcg/kg/min. The pharmacy has provided a solution of dopamine 400 mg in 250 mL D5W. The client weighs 198 lbs. Which of the following actions should the nurse take? a. Admin the dopamine using an infusion pump set at a rate of 16.9 ml/hr b. Document the client’s serum level before admin the med c. Verify the calculation of the infusion pump rate with the PHCP d. Contact the pharmacy and request a concentration of dopamine 800 mg in 500 mL D5W 50. The nurse is caring for assigned clients. Which of the clients should the nurse identify as being at risk for developing distributive shock? a. The client who was admitted with hemophilia and required a factor VIII infusion b. The client who was admitted 12 hrs ago with a SCI due to diving accident c. The client who developed ventricular fibrillation following a MI d. The client who developed AKI following total hip replacement surgery 4 days ago