NU 185
Exam 3 Medical-Surgical Nursing II Comprehensive
Quiz
Exam 3 • Practice Questions & Rationales
UPDATE
Actual Questions & Verified Answers
with Detailed Clinical Rationales
Practice Questions with Rationales
Galen College of Nursing
NU 185
✓ 100% Verified Answers
✓ Complete Rationales Included
Exam (elaborations)
Instant PDF Download • Ready for Study
,NU 185 Exam 3 Medical-Surgical Nursing II Comprehensive Quiz 2026/2027 UPDATE – Galen
1. A patient with a traumatic brain injury (TBI) exhibits a heart rate of 50 bpm, a blood
pressure of 190/60 mmHg, and irregular respirations. Which action should the nurse
prioritize?
A. Administer a bolus of intravenous normal saline
B. Prepare for immediate endotracheal intubation
C. Elevate the head of the bed to 30 degrees and contact the surgeon
D. Increase the sedation rate of Propofol
Answer: C
Rationale: The patient is exhibiting Cushing’s Triad (bradycardia, widened pulse
pressure/hypertension, and irregular respirations), a late sign of increased intracranial
pressure (ICP). Elevating the head of the bed is a primary nursing intervention to facilitate
venous drainage and lower ICP.
2. A client with a C6 spinal cord injury reports a sudden, throbbing headache and is found to
have a blood pressure of 210/110 mmHg. What is the nurse’s first action?
A. Administer PRN hydralazine intravenously
B. Call a Rapid Response Team immediately
C. Place the client in a supine position to prevent falls
, D. Check the client’s bladder for distension or a kinked catheter
Answer: D
Rationale: The symptoms suggest autonomic dysreflexia, a medical emergency triggered
by noxious stimuli below the level of injury, most commonly a full bladder. The first
nursing action is to identify and remove the trigger while sitting the patient upright.
3. Which arterial blood gas (ABG) result is most indicative of a patient in the early stages of
Acute Respiratory Distress Syndrome (ARDS)?
A. pH 7.30, PaCO2 55, PaO2 60
B. pH 7.35, PaCO2 45, PaO2 85
C. pH 7.48, PaCO2 30, PaO2 65
D. pH 7.25, PaCO2 60, PaO2 50
Answer: C
Rationale: In early ARDS, patients typically hyperventilate due to hypoxia, resulting in
respiratory alkalosis (high pH, low PaCO2) and a low PaO2 despite oxygen therapy.
4. A nurse is caring for a patient on a mechanical ventilator. The high-pressure alarm sounds.
Which condition should the nurse assess for?
A. Disconnection of the ventilator tubing
B. A leak in the endotracheal tube cuff
C. Extubation of the patient
Exam 3 Medical-Surgical Nursing II Comprehensive
Quiz
Exam 3 • Practice Questions & Rationales
UPDATE
Actual Questions & Verified Answers
with Detailed Clinical Rationales
Practice Questions with Rationales
Galen College of Nursing
NU 185
✓ 100% Verified Answers
✓ Complete Rationales Included
Exam (elaborations)
Instant PDF Download • Ready for Study
,NU 185 Exam 3 Medical-Surgical Nursing II Comprehensive Quiz 2026/2027 UPDATE – Galen
1. A patient with a traumatic brain injury (TBI) exhibits a heart rate of 50 bpm, a blood
pressure of 190/60 mmHg, and irregular respirations. Which action should the nurse
prioritize?
A. Administer a bolus of intravenous normal saline
B. Prepare for immediate endotracheal intubation
C. Elevate the head of the bed to 30 degrees and contact the surgeon
D. Increase the sedation rate of Propofol
Answer: C
Rationale: The patient is exhibiting Cushing’s Triad (bradycardia, widened pulse
pressure/hypertension, and irregular respirations), a late sign of increased intracranial
pressure (ICP). Elevating the head of the bed is a primary nursing intervention to facilitate
venous drainage and lower ICP.
2. A client with a C6 spinal cord injury reports a sudden, throbbing headache and is found to
have a blood pressure of 210/110 mmHg. What is the nurse’s first action?
A. Administer PRN hydralazine intravenously
B. Call a Rapid Response Team immediately
C. Place the client in a supine position to prevent falls
, D. Check the client’s bladder for distension or a kinked catheter
Answer: D
Rationale: The symptoms suggest autonomic dysreflexia, a medical emergency triggered
by noxious stimuli below the level of injury, most commonly a full bladder. The first
nursing action is to identify and remove the trigger while sitting the patient upright.
3. Which arterial blood gas (ABG) result is most indicative of a patient in the early stages of
Acute Respiratory Distress Syndrome (ARDS)?
A. pH 7.30, PaCO2 55, PaO2 60
B. pH 7.35, PaCO2 45, PaO2 85
C. pH 7.48, PaCO2 30, PaO2 65
D. pH 7.25, PaCO2 60, PaO2 50
Answer: C
Rationale: In early ARDS, patients typically hyperventilate due to hypoxia, resulting in
respiratory alkalosis (high pH, low PaCO2) and a low PaO2 despite oxygen therapy.
4. A nurse is caring for a patient on a mechanical ventilator. The high-pressure alarm sounds.
Which condition should the nurse assess for?
A. Disconnection of the ventilator tubing
B. A leak in the endotracheal tube cuff
C. Extubation of the patient
