NUR 265 / NUR265 EXAM 3
ADVANCED CONCEPTS IN
MEDICAL-SURGICAL NURSING
EXAM 3 | QUESTIONS AND
ANSWERS RATED A+ |
2026/2027
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 emergency
department 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."
ADVANCED CONCEPTS IN
MEDICAL-SURGICAL NURSING
EXAM 3 | QUESTIONS AND
ANSWERS RATED A+ |
2026/2027
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 emergency
department 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."
