NUR 265 Advanced Medical-
Surgical Nursing Exam 3
2026/2027 – Questions and
Answers | 100% Verified |
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1. Neurological & Critical Care
The nurse is caring for a client admitted with a head injury. One
hour ago, the client's vital signs were: T 98.6°F, P 110, R 26, BP
128/68 mm Hg. Current vital signs 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: The combination of bradycardia (Pulse 56),
hypertension, and irregular respirations is a classic presentation
of Cushing's triad, which indicates increased intracranial pressure
, (ICP) and potential brain herniation. This change from the
previous vital signs is an ominous sign requiring immediate
intervention .
2. Gastrointestinal Disorders
A client with acute pancreatitis is expected to have which lab
finding?
A. WBC count of 15,000/mm³
B. Decreased serum amylase
C. Normal sedimentation rate
D. Decreased blood glucose
Correct Answer: A. WBC count of 15,000/mm³
Rationale: Acute pancreatitis causes a significant systemic
inflammatory response. This leads to elevated white blood cell
(WBC) counts, as well as increased serum amylase and lipase.
Hyperglycemia, not hypoglycemia, may also occur .
3. Neurological Disorders
The nurse is assessing a client suspected of having myasthenia
gravis. Which findings are expected?
Fatigue
Dysphagia
Double Vision
Muscle Weakness
A. Only Fatigue and Muscle Weakness
B. Fatigue, Dysphagia, and Double Vision
C. Fatigue, Dysphagia, Double Vision, and Muscle Weakness
D. Dysphagia and Fatigue only
,Correct Answer: C. Fatigue, Dysphagia, Double Vision, and
Muscle Weakness
Rationale: Myasthenia gravis is characterized by fluctuating
muscle weakness that worsens with activity and improves with
rest. Common manifestations include fatigue, dysphagia (difficulty
swallowing), diplopia (double vision), and generalized muscle
weakness .
4. Spinal Cord Injury
The nurse is caring for a client who sustained a spinal cord injury
(SCI) at the level of C5 1 hour ago. Which is the priority nursing
intervention?
A. Monitor for urinary retention
B. Elevate the head of the bed to prevent pressure ulcers
C. Closely monitor respirations and respiratory effort
D. Encourage active range of motion exercises
Correct Answer: C. Closely monitor respirations and respiratory
effort
Rationale: A C5 injury can impair diaphragmatic and intercostal
muscle function, leading to respiratory compromise. Respiratory
failure is a leading cause of early mortality in cervical SCI, making
airway and breathing the highest priority .
5. Burns & Triage
A patient arrives at the emergency department with burns to the
entire left arm and the anterior trunk. Using the Rule of Nines,
what is the estimated total body surface area (TBSA) burned?
A. 18%
B. 45%
, C. 36%
D. 27%
Correct Answer: D. 27%
Rationale: According to the Rule of Nines, the entire left arm is
9% and the anterior trunk is 18%. The total estimated TBSA is 9%
+ 18% = 27% .
6. A client with encephalitis is prescribed an antiviral
medication. Which of the following should the nurse expect
to administer?
A. Ceftriaxone
B. Acyclovir
C. Rifampin
D. Fluconazole
Correct Answer: B. Acyclovir
Rationale: Acyclovir is the antiviral medication used to treat viral
encephalitis, especially herpes simplex encephalitis.
7. The nurse is caring for a client with encephalitis. Which is
the most serious complication of this condition?
A. Peripheral neuropathy
B. Increased ICP leading to herniation
C. Urinary tract infection
D. Seizure disorder
Correct Answer: B. Increased ICP leading to herniation
Rationale: The most serious complication of encephalitis is
increased intracranial pressure (ICP), which can lead to brain
herniation.
Surgical Nursing Exam 3
2026/2027 – Questions and
Answers | 100% Verified |
Complete Verified Answers – Pass
Guaranteed – A+ Graded| Instant
Download
1. Neurological & Critical Care
The nurse is caring for a client admitted with a head injury. One
hour ago, the client's vital signs were: T 98.6°F, P 110, R 26, BP
128/68 mm Hg. Current vital signs 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: The combination of bradycardia (Pulse 56),
hypertension, and irregular respirations is a classic presentation
of Cushing's triad, which indicates increased intracranial pressure
, (ICP) and potential brain herniation. This change from the
previous vital signs is an ominous sign requiring immediate
intervention .
2. Gastrointestinal Disorders
A client with acute pancreatitis is expected to have which lab
finding?
A. WBC count of 15,000/mm³
B. Decreased serum amylase
C. Normal sedimentation rate
D. Decreased blood glucose
Correct Answer: A. WBC count of 15,000/mm³
Rationale: Acute pancreatitis causes a significant systemic
inflammatory response. This leads to elevated white blood cell
(WBC) counts, as well as increased serum amylase and lipase.
Hyperglycemia, not hypoglycemia, may also occur .
3. Neurological Disorders
The nurse is assessing a client suspected of having myasthenia
gravis. Which findings are expected?
Fatigue
Dysphagia
Double Vision
Muscle Weakness
A. Only Fatigue and Muscle Weakness
B. Fatigue, Dysphagia, and Double Vision
C. Fatigue, Dysphagia, Double Vision, and Muscle Weakness
D. Dysphagia and Fatigue only
,Correct Answer: C. Fatigue, Dysphagia, Double Vision, and
Muscle Weakness
Rationale: Myasthenia gravis is characterized by fluctuating
muscle weakness that worsens with activity and improves with
rest. Common manifestations include fatigue, dysphagia (difficulty
swallowing), diplopia (double vision), and generalized muscle
weakness .
4. Spinal Cord Injury
The nurse is caring for a client who sustained a spinal cord injury
(SCI) at the level of C5 1 hour ago. Which is the priority nursing
intervention?
A. Monitor for urinary retention
B. Elevate the head of the bed to prevent pressure ulcers
C. Closely monitor respirations and respiratory effort
D. Encourage active range of motion exercises
Correct Answer: C. Closely monitor respirations and respiratory
effort
Rationale: A C5 injury can impair diaphragmatic and intercostal
muscle function, leading to respiratory compromise. Respiratory
failure is a leading cause of early mortality in cervical SCI, making
airway and breathing the highest priority .
5. Burns & Triage
A patient arrives at the emergency department with burns to the
entire left arm and the anterior trunk. Using the Rule of Nines,
what is the estimated total body surface area (TBSA) burned?
A. 18%
B. 45%
, C. 36%
D. 27%
Correct Answer: D. 27%
Rationale: According to the Rule of Nines, the entire left arm is
9% and the anterior trunk is 18%. The total estimated TBSA is 9%
+ 18% = 27% .
6. A client with encephalitis is prescribed an antiviral
medication. Which of the following should the nurse expect
to administer?
A. Ceftriaxone
B. Acyclovir
C. Rifampin
D. Fluconazole
Correct Answer: B. Acyclovir
Rationale: Acyclovir is the antiviral medication used to treat viral
encephalitis, especially herpes simplex encephalitis.
7. The nurse is caring for a client with encephalitis. Which is
the most serious complication of this condition?
A. Peripheral neuropathy
B. Increased ICP leading to herniation
C. Urinary tract infection
D. Seizure disorder
Correct Answer: B. Increased ICP leading to herniation
Rationale: The most serious complication of encephalitis is
increased intracranial pressure (ICP), which can lead to brain
herniation.
