NUR 265 Exam 3 | Questions and Answers | Fall 2025/26 Update | 100% Correct.

NUR 265 Exam 3 | Questions and Answers | Fall 2025/26 Update | 100% Correct. 1.) The nurse is caring for an adult client who was recently admitted with a head injury following a motor vehicle crash. One hour ago, the client's vital signs (VS) were temperature (T): 98.6° F; pulse (P): 110; respirations (R): 26; blood pressure (BP): 128/68 mm Hg. Which of the following findings is a priority for the nurse to follow up? P: 90; R: 32; BP: 130/72 mm Hg.- P: 120; R: 26, BP: 110/70 mm_ Hg. P: 56; R: 14; BP: 166/52 mm Hg. P: 64, R: 30; BP: 148/78m Hg. 2.) The nurse is caring for a client who sustained a closed head injury, is receiving mechanical ventilation, and is at risk for developing increased intracranial pressure (ICP). Which of the following actions should the nurse take when caring for this client? Perform passive range of motion (ROM) to the client's hips and knees. Log roll the client during turning and repositioning. Elevate the foot of the client's bed. Notify the charge nurse if the client's PaCO2, decreases from 39 to 35 mm Hg. 3.) The newly hired nurse is caring for a client who was admitted 12 hours ago with a traumatic brain injury (TBI), is intubated, and is at risk for developing increased intracranial pressure (ICP). Which interventions from the box below should the nurse include in the client's plan of care? 1 Avoid clustering client care activities. 2 Maintain the head in a flexed position. 3 Provide a quiet environment by limiting visitors.4 Have the client cough and deep breathe every hour. 5 Hyper oxygenate the client before and after suctioning.6. Avoid maintaining hips in a flexed position. 1, 3, 4, 5. 1, 3, 5, 6. 1, 2, 4, 6. 2, 4, 6. 4.) The nurse working in the intensive care unit (ICU) is assessing a client who sustained a basilar skull fracture 24 hours ago. It is most important to follow up with the primary health care provider (PHCP) if the client becomes irritable and restless. has bruises under the eyes. is unable to name the state capital. reports having a persistent headache since admission. 5.) The nurse is assessing a client who has experienced a mild traumatic brain injury (TBI). Which findings from the box below are consistent with this diagnosis? 1 Dizziness and gait problems. 2 A widened pulse pressure. 3 Increased sensitivity to light or noise. 4 A Glasgow Coma Scale (GCS) score of 9. 5 Dilated pupils that are nopreactive to light. 6 Amnesia about the events around the time of injury. 1, 3, 6. 3, 5, 6. 2, 3, 4, 5. 1, 2, 4, 6. 6.) The nurse is providing discharge instructions to the parents of a 15-year-old female who sustained a concussion while plaving field back Which of the following statements by a parent indicates a need for further teaching? "We should avoid giving any acetaminophen to treat headaches. "We need to bring our daughter back te the emergencydepartment if she exhibits blurred vision." "We should provide a consistent routine at home to assist with any behavior changes." "We will not allow our daughter to engage in strenuous activity for at least 48 hours." 7.) The nurse is assessing clients for the risk of sustaining a traumatic brain injury (TBI). Which of the following clients should the nurse identify as being at greatest risk? 45-year-old who has epilepsy and takes phenytoin. 75-year-old who lives alone and has macular degeneration. 7-year-old who is learning how to ride a bicycle without training wheels. 20-year-old college student who participates on the tennis team. 8.) The 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 need for farther teaching? "It is expected that my partner will have drainage from the nose for the next few days." "I will provide my partner with aeetaminophen every 4 hours for headache." "I will ensure my partner avoids strenuous activity for the next 48 hours." "I will avoid giving my partner their scheduled lorazepam for at least the next 24 hours." 9.) The nurse is caring for a client who is postoperative following a craniotomy and has developed syndrome of inappropriate antidiuretichormone (SIADH). Which of the following actions should the purse take? Remove salt packets from the client's meal tray. Change IV fluids to 0.45% sodium chloride (half-strength saline). Initiate a prescribed fluid restriction. Administer oral desmopressin acetate. 10.) The nurse is caring for the following assigned clients. Which client should the nurse see first? The client who has bacterial meningitis and has become lethargic. The client who has a mild traumatic brain injury (BI) and is reporting dizziness and insomnia. The client who has a concussion and is irritable and reporting a headache. The client who has a skull fracture, is alert and oriented, and reports feeling nauseated. 11.) The nurse is caring for a client who has meningitis. It is a priority for the nurse to follow up if reports the development of fatigue. has a change in Glasgow Coma Scale (GCS) score from 12 to 14 over the past 4 hours. has a change in blood pressure (BP) from 132/75 to 160/56 mm Hg. reports sensitivity to light.12.) The nurse is admitting a client who is diagnosed with bacterial meningitis. Which of the following actions should the nurse take first? Assess the eyes for pupillary shape and movement. Teach the client about the condition and treatment. Determine who the client has been in contact with. Administer an antiepileptic medication. 13.) The nurse working in the emergency department (ED) is admitting a client who is a college student and lives in a dormitory. The client has chills, nuchal rigidity, and a temperature (T) of 101.5° F. Which of the following actions should the nurse take first? 14.) The nurse is caring for a newly admitted client who sustained a spinal cord injury (SCI) at the level of T5 and has the following assessment findings: A decreased level of consciousness (LOC). Garbled speech. BP 82/44 mm Hg. P 56. Sa0, 88%. Which of the following actions should the nurse take immediately? Check the client for fecal impaction. Raise the head of bed (HOB) to a sitting position. Initiate an intravenous (IV) fluid bolus. Insert an indwelling urethral catheter. 15.) The nurse is caring for a client who sustained a spinal cord injury (SCI) at the level of C5 1 hour ago. Which of the following is a priority nursing intervention when planning care for this client? Perform a sensory assessment of the clients' extremities. Closely monitor respirations and respiratory effort.Continuous cardiac monitoring for bradycardia. Implement spinal cord immobilization. 16.) The nurse is caring for a client who has paraplegia and is being transferred to a rehabilitation facility. The client states to the nurse, "I don't want rehab, it won't work; I will never be able to walk again." Which of the following responses is appropriate for the nurse to initially make to the client? "I am sure this seems very scary for you, would you like me to contact a counselor to speak with you? "Rehab can help with your mobility; it just takes some time to see the benefits it will provide." "I am hearing you say that rehab will not work. Tell me more about how you are feeling." "Would you like for me to arrange for you to speak to someone who has had success with rehab?" 17.) The nurse is assessing a client who is suspected of having myasthenia gravis. Which findings from the box below does the nurse expect to observe in this client? 1 Fatigue.- 2 Dysphagia. 3 Constipation. 4 Shuffling gait.- 5 Double vision. 6 Muscle weakness.- 1, 2, 5, 6. 2, 3, 6. 1, 3, 4, 5. 4, 5, 6. 18.) The nurse is caring for a client who has myasthenia gravis and is receiving the prescribed cholinesterase (ChE) inhibitor, pyridostigmine. Whichof the following findings indicates that the client is having a therapeutic response to the medication? Decreased vertigo Increased muscular strength. Decreased pulse rate. Increased salivary secretions. 19.) The nurse is caring for a client who had an open craniotomy for a tumor resection 8 hours ago. Which client findings from the box below require immediate follow-up by the nurse? 1 A serum hematocrit (Hct) of 26%.-Y 2 A serum sodium level of 140 mEg/L.-N 3 Periorbital edema and ecchymosis of eyes bilaterally.-N 4 A urine output of 100 mL in the past 1 hour.-N 5 An output of 120 mL of sanguineous drainage from the closed-wound drainage system (JP) 2, 3, 4. 1, 2, 3. 1, 5. 2, 4. 20.) The nurse is caring for a client who sustained a severe traumatic brain injury (TBI) 2 hours ago. Which client findings from the box below require the nurse to follow up with the primary health care provider (PHCP)? 1 PaCO, of 52 mm Hg. 2 Pa0, of 88 mm Hg. 3 T 101.3 °F. 4 Serum sodium level of 144 mEg/L. 5 MAP 50 mm Hg. 1, 2, 3, 4. 2, 4, 5. 1, 3, 5.2, 3, 4, 5. 21.) The nurse has become aware of the following client situations. It is necessary for the nurse to initially assess the client who has Guillain-Barré syndrome (GBS) and is reporting lower extremity muscle weakness. myasthenia gravis and is reporting muscle achiness and blurred vision. a spinal cord injury (SCI) at the level of T6 and has not had a bowel movement since yesterday. amyotrophic lateral sclerosis (ALS) and coughs when attempting to eat and drink. 22.) The nurse is caring for a client who was recently admitted to an acute care facility with the diagnosis of Guillain-Barré syndrome (GBS). Which of the following should the nurse anticipate will be prescribed for the client? Plasmapheresis. A corticosteroid. Cryoprecipitate. A cholinesterase (ChE) inhibitor. 23.) The nurse is developing a plan of care for a client who has had amyotrophic lateral sclerosis (ALS) for the past 3 years and has been readmitted to an acute care facility with difficulty breathing. Which of the following should the nurse incrude in the client's plan of care? Educate the family about risk factors that exacerbate the illness. Check the client’s neurological status every hour. Suggest the need for the client to have a sitter around the clock. Refer the client to a hospice program for supportive care. 24.) The nurse is caring for assigned clients. It is most appropriate for a nurse to initiate an interdisciplinarycare conference for a client who is a 73-year-old male who is being discharged following a transient ischemic attack (TIA). 65-year-old male who sustained a traumatic brain injury (BI) and will require enteral nutrition for dysphagia after discharge. 45-year-old female who has been diagnosed with multiple sclerosis (MS) and will require corticosteroids after discharge. 35-year-old male who had a concussion from a fall and has had amnesia for the past 7 days. 25.) The nurse is reviewing newly written prescriptions for recently admitted clients. It is a priority for the nurse to follow up with the primary health care provider (PHCP) for a client a suspected cholinergic crisis and has been prescribed pyridostigmine. increased intracranial pressure (IC) has been prescribed the osmotic diuretic, mannitol. a full-thickness burn and has been prescribed the proton pump inhibitor (PPI), pantoprazole. a brain tumor and has been prescribed the antiepileptic, carbamazepine. 26.) The nurse is using the rule of nines to calculate the extent of a client's burn injury. The client has burns to the entire circumference of both arms. The nurse should document that the percent of total body surface area (TBS) burned is 18%. 36%. 45%. 9%. 27.) The nurse is caring for a male client whosustained full-thickness burns on the back and the posterior legs 6 hours ago. Which of the following laboratory values is an initial expected finding? A hematocrit (Hct) level of 40%. A white blood cell (WBC) count of 30,000 mm. A serum potassium level of 5.6. An elevated carboxyhemoglobin (COHb) level. 28.) The nurse is caring for a client who sustained burns to the mouth. During the change-of-shift assessment, the nurse notes that this client has fine wheezes. Two hours later the nurse notes that the client is no longer wheezing. Which of the following actions should the nurse take next? Loosen any constrictive clothing around the chest. Gather equipment in preparation for intubation. Document findings and reassess in 30 minutes. Raise the client's head of bed (HOB) to a semi-Fowler's position. 29.) The nurse is caring for assigned clients. It is a priority for the nurse to recommend an interdisciplinary care conference for the client who is 55 years old and recently underwent a transnasal pituitary tumor resection. 18 years old and recently diagnosed with a concussion and contusion Following a fall during an epileptic seizure. 50 years old and has sustained full-thickness burns over 40% of the body including the face and neck 35 years old and recently started intravenous (IV)antibiotics for bacterial meningitis 30.) The nurse is caring for a client who sustained an electrical injury and was brought to the emergency department (ED) by a neighbor. It is appropriate for the nurse to initially assess the client's complete blood cell (CBC) counts and electrolyte levels. allergy to medications and obtain a prescription for intravenous (IV) fluids. entrance and exit sites and obtain cardiac enzymes. pulse rate and rhythm and obtain an electrocardiogram (ECG). 31.) The nurse is caring for a client who was admitted to the emergency department (ED) with deep fullthickness burns to the full anterior and posterior torso. The client weighs 154 lb. What is the amount of fluid replacement that will be required in the first 24 hours, using 4 ml/kg when calculating the fluid replacement? 4ML/KG/36% 10,080 mL. 5,040 mL. 15,120 mL. 12,600 mL. 32.) The nurse working in the emergency department (ED) is admitting a client who was in a house fire and sustained deep partial full-thickness and fullthickness burns to the chest, back, and arms. It is necessary for the nurse to initially follow-up with the primary health care provider (PHCP) if the client hasa cherry-red color to the face. a history of taking an immunosuppressant. vesicular breath sounds in the peripheral lung fields. a burned total body surface area (TBS) of 35%. 33.) The nurse is caring for a client who had an escharotomy performed 2 hours ago to the right lower portion of the arm. Which of the following assessment findings indicates a therapeutic response to the procedure? A capillary refill of 4 seconds in the affected extremity Palpation of a strong right radial pulse (P) of 72. The formation of granulation tissue in the wound bed. Development of serosanguineous drainage from the site. 34.) The nurse preceptor is observing a newly hired nurse care for assigned clients in a burn unit. It requires follow-up by the preceptor if the newly hired nurse informs a client that heterografts are generally obtained from pig skin. informs a client that the newly prescribed compression garment will need to be worn over the dressings for 23 hours a day gives a client a prescribed opioid analgesic PO 20 minutes prior to changing the client's applies an enzymatic debridement agent to black eschar tissue. 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 developed redness and edema at the wound edges extending to the non-burned skin. only been eating 2,500 calories per day for the last 4 days. an allergy to penicillin and has been prescribed the topical cream gentamicin sulfate. refused to attend physical therapy (PT) for the second day in a row. 36.) The nurse is admitting a client who has sustained burns on the chest, has singed nasal hairs, and appears confused. Which of the following actions should the nurse take first? Apply oxygen at 3 L/min via nasal cannula. Assess the client's neurological status. Connect the client to a telemetry monitor. Determine if the client has a patent IV. 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 change in skin color from pale to bright-red. An increase in the capillary refill from 2 to 3 seconds. A decrease in quality of the pedal pulse. An increase in skin temperature from cool to warm. 38.) The nurse is caring for a client who weighs 182 lband sustained burns over 55% of the total body surface area (TBSA). It requires follow-up with the primary health care provider (PHCP) if the client's urine output is noted to be. 0.6 mL/kg/hr. 500 mL over 24 hours. 300 mL over 8 hours. 1 mL/kg/hr 39.) The nurse is caring for a 79-year-old female client who was admitted with a urinary tract infection (UTI) and is suspected of developing sepsis with systemic inflammatory response syndrome (SIRS). Which of the following findings does the nurse recognize as being consistent with this diagnosis? Blood pressure (BP) of 150/46 mm Hg and an irregularly irregular pulse. White blood cell (WBC) count of 10,500 mm° and a hemoglobin (Hgb) level of 8.9 mg/dL. Respirations (R) of 10, PaCO2 of 48 mm Hg, and the presence of wheezes in the bases. Pulse (P) of 110, temperature (T) of 96.4° F, and blood glucose level of 140 mg/dL 40.) The nurse working on a medical-surgical unit is participating in an interdisciplinary care conference. Which of the following clients should the nurse identify as being at greatest risk for the development of sepsis and septic shock? 63-year-old who has diabetes mellitus (type 2) and sustained a moderate head injury50-year old who had aortic valve repair 4 weeks ago 79-year-old who requires a feeding tube and has a sacral pressure ulcer (stage 3). 32-year-old who has a spinal cord injury (SCI) and has a mean arterial pressure (MAP) of 58 mmHg. 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 which of the following positions? Supine with head and feet flat. Head of bed (HOB) flat with the feet elevated. Side-lying with head of bed (HOB) elevated 15 degrees. Head of bed (HOB) elevated 45 degrees. 42.) The nurse working in the post anesthesia care unit (PACU) is caring for a client who had an abdominal aortic aneurysm (AAA) repair. Which of the following assessment findings suggests that the client is in the progressive stage of hypovolemic shock? An elevated serum lactate level of 10 mg/dL. A change in pupillary response to light from 4 to 6 mm. A decrease in the client's mean arterial pressure (MAP) of 10 mm Hg from baseline. A decrease in respirations (R) from 28 to 14. 43.) The nurse is caring for a client who has developed septic shock. Which of the following findings indicates that the client is responding to the treatment? Maintenance of urine output of 30 mL/hr.Maintenance of a mean arterial pressure (MAP) of 50 mm Hg. Maintenance of a serum pH level of 7.32. Maintenance of serum blood glucose of 100 to 160 mg/dL. 44.) The nurse is caring for a client who is in cardiogenic shock and has been prescribed a continuous infusion of milrinone. The nurse recognizes that the purpose of administering this medication is to dilate the client's coronary arteries. promote vasoconstriction. increase myocardial contractility decrease the client's pulse. 45.) The nurse is caring for a client who is 1 day postoperative, has an intravenous (IV) infusion of 0.9% sodium chloride (normal saline), an indwelling urethral catheter with hourly output measurements, and the assessment findings indicated in the table below. Tachycardia RR increased from 18 to 20 SaO2 decreased from 98% to 95% Urine output decreased Skin is now cool and clammy Potassium @ 5.2 Which of the following actions should the nurse take next? Start IV regular insulin by continuous infusion. Assess the client's capillary blood glucose level. Obtain a blood specimen for type and cross match. Assess the client's level of consciousness (LOC) andorientation. 46.) The nurse is caring for a 17-year-old client involved in a motor vehicle crash who is in the refractory stage of shock. Which of the following actions is appropriate for the nurse to take? Recommend to the case manager that the client receive a referral for placement in a long-term acute care (LTAC) facility. Monitor the client's urine output once every 15 minutes. Use lactated ringers solution when administering (PRBCS) prescribed unit of packed red blood cells Determine if the family would like to spend time at the client's bedside. 47.) The nurse is caring for a client who has developed obstructive shock. Which diagnoses from the box below documented in the client's history should the nurse correlate to this problem? 1 Cardiomyopathy. 2 Cardiac tamponade. 3 Myocardial infarction (MI). 4 Tension pneumothorax. 5 Ventricular dysrhythmias. 6 Pulmonary embolism (PE). 1, 2, 3. 4, 5, 6. 3, 4, 6. 2, 4, 6. 48.) The nurse is caring for a client who is in cardiogenic shock and has been started on a continuous infusion of dobutamine. It is a priority for the nurse to notify the primary health care provider (PHCP) if the clientreports feeling warm and flushed. has an increase of 10 mm Hg in the mean arterial pressure (MAP). reports the development of pain in the jaw. has a decrease in urine output from 100 to 60 mL/hr. 49.) The nurse is caring for a client who has been prescribed a 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 5% dextrose in water. The client weighs 198 lbs. Which of the following actions should the nurse take? Document the client's serum creatinine level before administering the medication. Verify the calculation of the infusion pump rate with the primary health care provider (PHCP). Administer the dopamine using an infusion pump set at a rate of 16.9 mL/hr. Contact the pharmacy and request a concentration of dopamine 800 mg in 500 mL 5% dextrose in water 50.) The nurse is caring for assigned clients. Which of the following clients should the nurse identify as being at risk for developing distributive shock? The client who was admitted 1 hour ago with hives and angioedema after eating shellfish. The client who developed acute kidney injury (AKI) following total hip replacement surgery 4 days ago. The client who developed ventricular fibrillation following a myocardial infarction (MI). The client who was admitted with hemophilia and requireda factor VIll infusion.