NUR 265
EXAM 3
Medical-Surgical Nursing
Galen College of Nursing
Tested Qs & Verified Answers with Rationales
This Exam Features:
NUR 265 Exam 3 Medical-Surgical Nursing (Galen
College) including 50 Tested questions written
to mirror actual course exams. Covers core Med-
Surg concepts with clear, accurate, and student-
friendly explanations. Perfect for mastering high-priority topics
and boosting exam confidence.
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 were: T 98.6°F, P 110, R 26, BP 128/68 mm Hg. The
current VS are: P 56, R 14, BP 166/52 mm Hg. Which of the following
findings is a priority for the nurse to follow up?
A. Pulse 56 bpm
B. Respirations 14 per minute
C. Blood pressure 166/52 mm Hg
D. Temperature 98.6°F
Correct Answer: A. Pulse 56 bpm
Rationale: Bradycardia combined with hypertension and irregular
respirations may indicate Cushing's triad, a classic sign of increased
intracranial pressure (ICP) and impending brain herniation. The decrease in
pulse rate from 110 to 56 bpm with a rising blood pressure is an ominous
neurological sign requiring immediate attention. The respiratory rate of 14
is within normal limits.
---
2. The nurse is caring for a client with a closed head injury who is
receiving mechanical ventilation and is at risk for increased ICP.
Which of the following actions should the nurse take when caring for
this client?
A. Log roll the client during turning and repositioning
B. Perform frequent head and neck flexion exercises
C. Cluster care activities to minimize disturbance
D. Keep the client flat in bed to improve cerebral perfusion
Correct Answer: A. Log roll the client during turning and repositioning
Rationale: Log rolling maintains spinal alignment and prevents increased
ICP by avoiding neck flexion or rotation. Frequent head and neck flexion
can increase ICP due to impaired venous drainage. Clustering care
, increases stimulation and ICP, so care should be spaced out instead.
Keeping the client flat is contraindicated; the head of the bed should be
elevated 30 degrees to promote venous drainage.
---
3. The newly hired nurse is caring for a client admitted 12 hours ago
with a traumatic brain injury (TBI), who is intubated and at risk for
increased ICP. Which interventions should the nurse include in the
client's plan of care? (Select all that apply.)
A. Avoid clustering client care activities
B. Provide a quiet environment by limiting visitors
C. Hyperoxygenate the client before and after suctioning
D. Avoid maintaining hips in a flexed position
E. Use frequent coughing and deep breathing
Correct Answers: A, B, C, D
Rationale: To prevent increases in ICP, cluster care should be avoided to
minimize stimulation; a quiet environment reduces stress;
hyperoxygenation before and after suctioning prevents hypoxia, which
elevates ICP; and extended hips promote venous return and decrease ICP.
Coughing can increase ICP and should be avoided or minimized.
---
4. The nurse 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 if the client:
A. Has a mild headache
B. Is drowsy but arousable
C. Becomes irritable and restless
D. Reports mild dizziness
EXAM 3
Medical-Surgical Nursing
Galen College of Nursing
Tested Qs & Verified Answers with Rationales
This Exam Features:
NUR 265 Exam 3 Medical-Surgical Nursing (Galen
College) including 50 Tested questions written
to mirror actual course exams. Covers core Med-
Surg concepts with clear, accurate, and student-
friendly explanations. Perfect for mastering high-priority topics
and boosting exam confidence.
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 were: T 98.6°F, P 110, R 26, BP 128/68 mm Hg. The
current VS are: P 56, R 14, BP 166/52 mm Hg. Which of the following
findings is a priority for the nurse to follow up?
A. Pulse 56 bpm
B. Respirations 14 per minute
C. Blood pressure 166/52 mm Hg
D. Temperature 98.6°F
Correct Answer: A. Pulse 56 bpm
Rationale: Bradycardia combined with hypertension and irregular
respirations may indicate Cushing's triad, a classic sign of increased
intracranial pressure (ICP) and impending brain herniation. The decrease in
pulse rate from 110 to 56 bpm with a rising blood pressure is an ominous
neurological sign requiring immediate attention. The respiratory rate of 14
is within normal limits.
---
2. The nurse is caring for a client with a closed head injury who is
receiving mechanical ventilation and is at risk for increased ICP.
Which of the following actions should the nurse take when caring for
this client?
A. Log roll the client during turning and repositioning
B. Perform frequent head and neck flexion exercises
C. Cluster care activities to minimize disturbance
D. Keep the client flat in bed to improve cerebral perfusion
Correct Answer: A. Log roll the client during turning and repositioning
Rationale: Log rolling maintains spinal alignment and prevents increased
ICP by avoiding neck flexion or rotation. Frequent head and neck flexion
can increase ICP due to impaired venous drainage. Clustering care
, increases stimulation and ICP, so care should be spaced out instead.
Keeping the client flat is contraindicated; the head of the bed should be
elevated 30 degrees to promote venous drainage.
---
3. The newly hired nurse is caring for a client admitted 12 hours ago
with a traumatic brain injury (TBI), who is intubated and at risk for
increased ICP. Which interventions should the nurse include in the
client's plan of care? (Select all that apply.)
A. Avoid clustering client care activities
B. Provide a quiet environment by limiting visitors
C. Hyperoxygenate the client before and after suctioning
D. Avoid maintaining hips in a flexed position
E. Use frequent coughing and deep breathing
Correct Answers: A, B, C, D
Rationale: To prevent increases in ICP, cluster care should be avoided to
minimize stimulation; a quiet environment reduces stress;
hyperoxygenation before and after suctioning prevents hypoxia, which
elevates ICP; and extended hips promote venous return and decrease ICP.
Coughing can increase ICP and should be avoided or minimized.
---
4. The nurse 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 if the client:
A. Has a mild headache
B. Is drowsy but arousable
C. Becomes irritable and restless
D. Reports mild dizziness
