NSG 233 Med Surg 3 Exam 3
Herzing Questions and Ansẉers with
rationales 2026\2027 update
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Questions and Ansẉers
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,───────────────────────────────────────────────────────
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A patient with a suspected stroke is brought to the emergency
department. The healthcare provider prescribes alteplase (tPA).
Which of the following is the most critical intervention before
administering this medication?
A) Checking the patient's blood pressure
B) Obtaining a CT scan of the head without contrast
C) Performing a 12-lead electrocardiogram (ECG)
D) Drawing a basic metabolic panel (BMP)
Answer: B
Rationale: tPA is a thrombolytic used to treat ischemic stroke. It is
critical to obtain a CT scan first to rule out a hemorrhagic stroke, as
administering tPA to a patient with a hemorrhagic stroke would
cause fatal bleeding.
A nurse is assessing a patient with increased intracranial pressure
(ICP). Which of the following vital sign changes is a late sign of
increased ICP?
A) Tachycardia
B) Hypotension
C) Widened pulse pressure
D) Shallow, irregular respirations
Answer: C
Rationale: Cushing's triad (bradycardia, widening pulse pressure,
and irregular respirations) is a late and ominous sign of increased
ICP indicating brainstem herniation. Widened pulse pressure
(increased systolic with decreased diastolic) occurs first in the triad.
,A patient with a traumatic brain injury has a ventriculostomy in
place. The nurse notes the drainage has suddenly stopped. What is
the nurse's first action?
A) Flush the tubing with sterile normal saline
B) Check the system for kinks or clamps
C) Call the neurosurgeon immediately
D) Reposition the patient to supine
Answer: B
Rationale: The first action for any sudden cessation of drainage from
any drain is to check for mechanical obstructions such as kinks,
clamps, or the patient lying on the tubing. Flushing a
ventriculostomy is strictly contraindicated as it can introduce
infection or push fluid back into the ventricles, causing increased
ICP.
Which of the following patients is at the highest risk for
experiencing a hemorrhagic stroke?
A) A 45-year-old with atrial fibrillation
B) A 60-year-old with uncontrolled hypertension
C) A 70-year-old with a mechanical heart valve
D) A 50-year-old with type 2 diabetes mellitus
Answer: B
Rationale: Uncontrolled hypertension is the most significant risk
factor for a hemorrhagic stroke (bleeding into the brain tissue) due
to the weakening of cerebral blood vessels over time. Atrial
fibrillation and mechanical heart valves are risk factors for ischemic
strokes due to embolization.
A patient is admitted with a left-sided ischemic stroke. Which of the
following deficits should the nurse expect to find?
A) Right-sided hemiparesis and aphasia
B) Left-sided hemiparesis and right visual field deficit
, C) Right-sided hemiparesis and left visual field deficit
D) Left-sided hemiplegia and aphasia
Answer: A
Rationale: The brain is contralateral, meaning a left-sided brain
injury causes right-sided motor deficits (hemiparesis). Furthermore,
the left hemisphere is typically the dominant hemisphere for
language in most people, so a left-sided stroke often causes
aphasia.
The nurse is caring for a patient with a subarachnoid hemorrhage
(SAH). Which of the following interventions is most critical to
prevent the most common complication of SAH?
A) Maintaining strict bed rest in a quiet, darkened room
B) Administering prescribed nimodipine (Nimotop)
C) Encouraging aggressive fluid intake
D) Performing frequent passive range of motion
Answer: B
Rationale: Cerebral vasospasm is the most common and severe
complication of a SAH, typically occurring 3 to 14 days after the
bleed. Nimodipine, a calcium channel blocker, is administered
specifically to prevent cerebral vasospasm.
A patient with Guillain-Barré syndrome (GBS) is experiencing
ascending paralysis. Which of the following assessments is the
highest priority for the nurse?
A) Monitoring urinary output
B) Assessing respiratory status
C) Evaluating gag reflex
D) Checking deep tendon reflexes
Answer: B
Rationale: GBS causes ascending paralysis, meaning it moves from
the lower extremities upward. The highest priority is assessing
Herzing Questions and Ansẉers with
rationales 2026\2027 update
This Exam contains:
Guarantee passing score
Questions and Ansẉers
format set of multiple-choice
Expert-Verified rationales
Verified ẉith trusted textbooks
,───────────────────────────────────────────────────────
─
A patient with a suspected stroke is brought to the emergency
department. The healthcare provider prescribes alteplase (tPA).
Which of the following is the most critical intervention before
administering this medication?
A) Checking the patient's blood pressure
B) Obtaining a CT scan of the head without contrast
C) Performing a 12-lead electrocardiogram (ECG)
D) Drawing a basic metabolic panel (BMP)
Answer: B
Rationale: tPA is a thrombolytic used to treat ischemic stroke. It is
critical to obtain a CT scan first to rule out a hemorrhagic stroke, as
administering tPA to a patient with a hemorrhagic stroke would
cause fatal bleeding.
A nurse is assessing a patient with increased intracranial pressure
(ICP). Which of the following vital sign changes is a late sign of
increased ICP?
A) Tachycardia
B) Hypotension
C) Widened pulse pressure
D) Shallow, irregular respirations
Answer: C
Rationale: Cushing's triad (bradycardia, widening pulse pressure,
and irregular respirations) is a late and ominous sign of increased
ICP indicating brainstem herniation. Widened pulse pressure
(increased systolic with decreased diastolic) occurs first in the triad.
,A patient with a traumatic brain injury has a ventriculostomy in
place. The nurse notes the drainage has suddenly stopped. What is
the nurse's first action?
A) Flush the tubing with sterile normal saline
B) Check the system for kinks or clamps
C) Call the neurosurgeon immediately
D) Reposition the patient to supine
Answer: B
Rationale: The first action for any sudden cessation of drainage from
any drain is to check for mechanical obstructions such as kinks,
clamps, or the patient lying on the tubing. Flushing a
ventriculostomy is strictly contraindicated as it can introduce
infection or push fluid back into the ventricles, causing increased
ICP.
Which of the following patients is at the highest risk for
experiencing a hemorrhagic stroke?
A) A 45-year-old with atrial fibrillation
B) A 60-year-old with uncontrolled hypertension
C) A 70-year-old with a mechanical heart valve
D) A 50-year-old with type 2 diabetes mellitus
Answer: B
Rationale: Uncontrolled hypertension is the most significant risk
factor for a hemorrhagic stroke (bleeding into the brain tissue) due
to the weakening of cerebral blood vessels over time. Atrial
fibrillation and mechanical heart valves are risk factors for ischemic
strokes due to embolization.
A patient is admitted with a left-sided ischemic stroke. Which of the
following deficits should the nurse expect to find?
A) Right-sided hemiparesis and aphasia
B) Left-sided hemiparesis and right visual field deficit
, C) Right-sided hemiparesis and left visual field deficit
D) Left-sided hemiplegia and aphasia
Answer: A
Rationale: The brain is contralateral, meaning a left-sided brain
injury causes right-sided motor deficits (hemiparesis). Furthermore,
the left hemisphere is typically the dominant hemisphere for
language in most people, so a left-sided stroke often causes
aphasia.
The nurse is caring for a patient with a subarachnoid hemorrhage
(SAH). Which of the following interventions is most critical to
prevent the most common complication of SAH?
A) Maintaining strict bed rest in a quiet, darkened room
B) Administering prescribed nimodipine (Nimotop)
C) Encouraging aggressive fluid intake
D) Performing frequent passive range of motion
Answer: B
Rationale: Cerebral vasospasm is the most common and severe
complication of a SAH, typically occurring 3 to 14 days after the
bleed. Nimodipine, a calcium channel blocker, is administered
specifically to prevent cerebral vasospasm.
A patient with Guillain-Barré syndrome (GBS) is experiencing
ascending paralysis. Which of the following assessments is the
highest priority for the nurse?
A) Monitoring urinary output
B) Assessing respiratory status
C) Evaluating gag reflex
D) Checking deep tendon reflexes
Answer: B
Rationale: GBS causes ascending paralysis, meaning it moves from
the lower extremities upward. The highest priority is assessing
