NUR 265 EXAM 3
Medical-Surgical Nursing II
Comprehensive Practice Exam (45 Questions)
THIS DOCUMENT CONTAINS:
➢ GUARANTEE PASSING SCORE
➢ QUESTIONS AND ANSWERS
➢ EXPERT VERIFIED EXPLANATIONS
➢ FORMAT SET OF MULTIPLE-CHOICE
, Exam Topics Covered:
• Neurological Disorders: Traumatic Brain Injury (TBI), Increased Intracranial Pressure
(ICP), Meningitis, Seizures, Spinal Cord Injury (SCI), Autonomic Dysreflexia, Stroke.
• Critical Care & Shock: Hypovolemic, Cardiogenic, Septic, and Neurogenic Shock;
SIRS/MODS; Hemodynamics.
• Immunological Disorders: HIV/AIDS, Organ Transplantation, Anaphylaxis, Lupus
(SLE).
• Renal & Burns: Acute Kidney Injury (AKI), Dialysis, Burn Injury & Fluid Resuscitation.
Section 1: Neurological Disorders (TBI, ICP, Meningitis)
1. A client with a traumatic brain injury (TBI) has vital signs: P 56, R 14, BP
166/52 mm Hg. The nurse notes these are a change from previous vitals of P
110, R 26, BP 128/68. What is the priority nursing action?
A. Administer a beta-blocker for hypertension.
B. Recheck the blood pressure in 15 minutes.
C. Notify the provider immediately.
D. Increase the IV fluid rate.
Correct Answer: C. Notify the provider immediately.
Rationale: This triad of bradycardia, irregular respirations, and widening pulse
pressure (systolic hypertension) is Cushing’s Triad, a late and ominous sign of
severely increased ICP indicating brainstem compression. Immediate medical
intervention is required to prevent herniation .
2. Which intervention is essential for a nurse caring for a client with a closed
head injury and increased ICP?
A. Cluster all nursing activities to allow long rest periods.
B. Maintain the head of the bed flat to increase perfusion.
C. Logroll the client during turning and repositioning.
D. Encourage deep coughing and suctioning to clear airways.
Correct Answer: C. Logroll the client during turning and repositioning.
Rationale: Logrolling maintains spinal alignment and prevents jugular vein
compression, which helps avoid spikes in ICP. Clustering care (A) increases ICP due to
overstimulation. The HOB should be elevated 30 degrees (B) to promote venous
drainage. Coughing/suctioning (D) increases intrathoracic pressure, raising ICP .
3. A client with a basilar skull fracture has clear drainage from the nose. Which
action should the nurse take first?
A. Pack the nares tightly with gauze.
B. Test the drainage for glucose.
Medical-Surgical Nursing II
Comprehensive Practice Exam (45 Questions)
THIS DOCUMENT CONTAINS:
➢ GUARANTEE PASSING SCORE
➢ QUESTIONS AND ANSWERS
➢ EXPERT VERIFIED EXPLANATIONS
➢ FORMAT SET OF MULTIPLE-CHOICE
, Exam Topics Covered:
• Neurological Disorders: Traumatic Brain Injury (TBI), Increased Intracranial Pressure
(ICP), Meningitis, Seizures, Spinal Cord Injury (SCI), Autonomic Dysreflexia, Stroke.
• Critical Care & Shock: Hypovolemic, Cardiogenic, Septic, and Neurogenic Shock;
SIRS/MODS; Hemodynamics.
• Immunological Disorders: HIV/AIDS, Organ Transplantation, Anaphylaxis, Lupus
(SLE).
• Renal & Burns: Acute Kidney Injury (AKI), Dialysis, Burn Injury & Fluid Resuscitation.
Section 1: Neurological Disorders (TBI, ICP, Meningitis)
1. A client with a traumatic brain injury (TBI) has vital signs: P 56, R 14, BP
166/52 mm Hg. The nurse notes these are a change from previous vitals of P
110, R 26, BP 128/68. What is the priority nursing action?
A. Administer a beta-blocker for hypertension.
B. Recheck the blood pressure in 15 minutes.
C. Notify the provider immediately.
D. Increase the IV fluid rate.
Correct Answer: C. Notify the provider immediately.
Rationale: This triad of bradycardia, irregular respirations, and widening pulse
pressure (systolic hypertension) is Cushing’s Triad, a late and ominous sign of
severely increased ICP indicating brainstem compression. Immediate medical
intervention is required to prevent herniation .
2. Which intervention is essential for a nurse caring for a client with a closed
head injury and increased ICP?
A. Cluster all nursing activities to allow long rest periods.
B. Maintain the head of the bed flat to increase perfusion.
C. Logroll the client during turning and repositioning.
D. Encourage deep coughing and suctioning to clear airways.
Correct Answer: C. Logroll the client during turning and repositioning.
Rationale: Logrolling maintains spinal alignment and prevents jugular vein
compression, which helps avoid spikes in ICP. Clustering care (A) increases ICP due to
overstimulation. The HOB should be elevated 30 degrees (B) to promote venous
drainage. Coughing/suctioning (D) increases intrathoracic pressure, raising ICP .
3. A client with a basilar skull fracture has clear drainage from the nose. Which
action should the nurse take first?
A. Pack the nares tightly with gauze.
B. Test the drainage for glucose.
