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NUR 265 – MEDICAL-SURGICAL NURSING – EXAM 3
(NCLEX-STYLE) 2026/2027 COMPLETE CURRENT TESTING
QUESTIONS AND CORRECT ANSWERS WITH DETAILED
RATIONALES.
NURSING
Prepare for NUR 265 Exam 3 with this focused Medical-Surgical Nursing study
resource designed to reinforce essential nursing concepts and clinical knowledge.
Use it to review patient assessment, disease processes, nursing interventions, clinical
judgment, and key medical-surgical topics. This resource can help strengthen your
understanding, identify areas that may require additional study, and improve exam
readiness. It provides a structured supplement to your coursework for a more
confident approach to Exam 3.
MULTIPLE CHOICE.
Section 1: Neurological Disorders – TBI, ICP & Spinal Cord Injuries (Q1–
Q25)
1. A nurse is admitting a client who sustained a traumatic brain injury (TBI)
following a motor vehicle crash. It is a priority for the nurse to notify the
primary health care provider if the client:
A. Takes prescribed warfarin daily
B. Has a headache rated 4/10
C. Has a blood pressure reading of 120/80 mm Hg
D. Has no history of seizures
Answer: A
Rationale: Clients on warfarin are at increased risk for intracranial
hemorrhage after a TBI due to anticoagulation increasing the risk of
bleeding. Promptly informing the provider allows for rapid assessment
and possible reversal of anticoagulation to prevent secondary brain
injury.
2. The charge nurse observes a newly hired nurse caring for a client who
sustained a closed head injury, is receiving mechanical ventilation, and is
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at risk for developing increased intracranial pressure (ICP). Which action
performed by the newly hired nurse requires intervention by the charge
nurse?
A. Raising the foot of the client's bed
B. Clustering client care activities
C. Maintaining the head of the bed elevated at 30 degrees
D. Administering analgesics as prescribed
Answer: A
Rationale: Raising the foot of the bed can increase ICP by reducing
venous drainage from the brain. Patients at risk for elevated ICP should
have the head of the bed elevated to promote venous return.
3. A new nurse is caring for a patient admitted 12 hours ago with a TBI who
is at risk for ICP. Which action requires intervention?
A. Clustering patient care activities
B. Maintaining head midline/neutral position
C. Suctioning the patient routinely every hour
D. Administering prescribed analgesics
Answer: A
Rationale: Clustering care activities can increase ICP by causing a
cumulative rise in intrathoracic pressure. Care should be spaced to allow
for rest periods.
4. When assessing patients for the risk of sustaining a TBI, which patient
should the nurse identify as being at greatest risk?
A. A 20-year-old college student who is on the football team
B. A 45-year-old office worker
C. A 60-year-old retiree
D. A 70-year-old with osteoporosis
Answer: A
Rationale: Young adults, particularly those participating in contact sports,
are at the highest risk for TBI.
5. A nurse has assigned patients. Which assessment finding would need
to be reported to the PCP?
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A. The development of asymmetric pupils with no reaction to light in a patient
who has a TBI
B. A headache rated 3/10
C. A blood pressure of 130/80 mm Hg
D. A temperature of 99.5°F
Answer: A
Rationale: Asymmetric pupils with no reaction to light indicate increased
ICP and possible brain herniation, which is life-threatening and requires
immediate provider notification.
6. A nurse is caring for a patient who had a TBI with a skull fracture. The
nurse notes that the patient has rhinorrhea and it is positive for glucose.
What action is next?
A. Perform a halo sign test
B. Document the finding as a normal expectation
C. Prepare for immediate surgery
D. Administer a nasal decongestant
Answer: A
Rationale: The halo sign test should be performed. Place the fluid on
white absorbent paper; a clear halo ring surrounding a bloody center
indicates CSF leakage.
7. A nurse is providing discharge teaching to a patient's partner who
sustained a mild head injury from a motor vehicle crash. Which statement
requires additional teaching?
A. "I will bring my partner to the ED if they immediately start vomiting."
B. "I will wake my partner every 2 hours to check their level of consciousness."
C. "I will monitor for changes in behavior or confusion."
D. "I will ensure my partner gets plenty of rest."
Answer: A
Rationale: Nausea and vomiting are expected symptoms of a mild head
injury and typically resolve within 72 hours. Additional teaching is needed
because this statement indicates a misunderstanding of expected
symptoms.
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8. A nurse is caring for the following patients. Which patient would the
nurse see first?
A. The patient who has a brain injury and a BP change from 110/58 to 134/40
B. The patient with a headache rated 5/10
C. The patient with a temperature of 100.2°F
D. The patient requesting pain medication
Answer: A
Rationale: The change in blood pressure (widening pulse pressure) is an
early sign of Cushing's triad, a late sign of increased ICP and impending
herniation. The provider must be notified immediately.
9. A 24-hour post-op craniotomy patient is reporting a headache 8/10.
What is the next step for the nurse to take?
A. Perform a neuro assessment
B. Administer the prescribed analgesic immediately
C. Document the finding and continue monitoring
D. Elevate the head of the bed to 90 degrees
Answer: A
Rationale: The nurse should first perform a neurological assessment to
determine if the headache is related to increased ICP or another
complication before administering medication.
10. Which clinical manifestation is a hallmark sign of the 'emergent
phase' of burn shock?
A. Increased blood pressure and heart rate
B. Decreased capillary refill and cool extremities
C. Hypertension and bradycardia
D. Polyuria and increased thirst
Answer: B
Rationale: The emergent phase of burn shock is characterized by
hypovolemia, decreased cardiac output, and poor tissue perfusion,
leading to decreased capillary refill and cool extremities.
11. A patient arrives at the emergency department with burns to the entire
left arm and the anterior trunk. Using the Rule of Nines, what percentage
NUR 265 – MEDICAL-SURGICAL NURSING – EXAM 3
(NCLEX-STYLE) 2026/2027 COMPLETE CURRENT TESTING
QUESTIONS AND CORRECT ANSWERS WITH DETAILED
RATIONALES.
NURSING
Prepare for NUR 265 Exam 3 with this focused Medical-Surgical Nursing study
resource designed to reinforce essential nursing concepts and clinical knowledge.
Use it to review patient assessment, disease processes, nursing interventions, clinical
judgment, and key medical-surgical topics. This resource can help strengthen your
understanding, identify areas that may require additional study, and improve exam
readiness. It provides a structured supplement to your coursework for a more
confident approach to Exam 3.
MULTIPLE CHOICE.
Section 1: Neurological Disorders – TBI, ICP & Spinal Cord Injuries (Q1–
Q25)
1. A nurse is admitting a client who sustained a traumatic brain injury (TBI)
following a motor vehicle crash. It is a priority for the nurse to notify the
primary health care provider if the client:
A. Takes prescribed warfarin daily
B. Has a headache rated 4/10
C. Has a blood pressure reading of 120/80 mm Hg
D. Has no history of seizures
Answer: A
Rationale: Clients on warfarin are at increased risk for intracranial
hemorrhage after a TBI due to anticoagulation increasing the risk of
bleeding. Promptly informing the provider allows for rapid assessment
and possible reversal of anticoagulation to prevent secondary brain
injury.
2. The charge nurse observes a newly hired nurse caring for a client who
sustained a closed head injury, is receiving mechanical ventilation, and is
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at risk for developing increased intracranial pressure (ICP). Which action
performed by the newly hired nurse requires intervention by the charge
nurse?
A. Raising the foot of the client's bed
B. Clustering client care activities
C. Maintaining the head of the bed elevated at 30 degrees
D. Administering analgesics as prescribed
Answer: A
Rationale: Raising the foot of the bed can increase ICP by reducing
venous drainage from the brain. Patients at risk for elevated ICP should
have the head of the bed elevated to promote venous return.
3. A new nurse is caring for a patient admitted 12 hours ago with a TBI who
is at risk for ICP. Which action requires intervention?
A. Clustering patient care activities
B. Maintaining head midline/neutral position
C. Suctioning the patient routinely every hour
D. Administering prescribed analgesics
Answer: A
Rationale: Clustering care activities can increase ICP by causing a
cumulative rise in intrathoracic pressure. Care should be spaced to allow
for rest periods.
4. When assessing patients for the risk of sustaining a TBI, which patient
should the nurse identify as being at greatest risk?
A. A 20-year-old college student who is on the football team
B. A 45-year-old office worker
C. A 60-year-old retiree
D. A 70-year-old with osteoporosis
Answer: A
Rationale: Young adults, particularly those participating in contact sports,
are at the highest risk for TBI.
5. A nurse has assigned patients. Which assessment finding would need
to be reported to the PCP?
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A. The development of asymmetric pupils with no reaction to light in a patient
who has a TBI
B. A headache rated 3/10
C. A blood pressure of 130/80 mm Hg
D. A temperature of 99.5°F
Answer: A
Rationale: Asymmetric pupils with no reaction to light indicate increased
ICP and possible brain herniation, which is life-threatening and requires
immediate provider notification.
6. A nurse is caring for a patient who had a TBI with a skull fracture. The
nurse notes that the patient has rhinorrhea and it is positive for glucose.
What action is next?
A. Perform a halo sign test
B. Document the finding as a normal expectation
C. Prepare for immediate surgery
D. Administer a nasal decongestant
Answer: A
Rationale: The halo sign test should be performed. Place the fluid on
white absorbent paper; a clear halo ring surrounding a bloody center
indicates CSF leakage.
7. A nurse is providing discharge teaching to a patient's partner who
sustained a mild head injury from a motor vehicle crash. Which statement
requires additional teaching?
A. "I will bring my partner to the ED if they immediately start vomiting."
B. "I will wake my partner every 2 hours to check their level of consciousness."
C. "I will monitor for changes in behavior or confusion."
D. "I will ensure my partner gets plenty of rest."
Answer: A
Rationale: Nausea and vomiting are expected symptoms of a mild head
injury and typically resolve within 72 hours. Additional teaching is needed
because this statement indicates a misunderstanding of expected
symptoms.
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8. A nurse is caring for the following patients. Which patient would the
nurse see first?
A. The patient who has a brain injury and a BP change from 110/58 to 134/40
B. The patient with a headache rated 5/10
C. The patient with a temperature of 100.2°F
D. The patient requesting pain medication
Answer: A
Rationale: The change in blood pressure (widening pulse pressure) is an
early sign of Cushing's triad, a late sign of increased ICP and impending
herniation. The provider must be notified immediately.
9. A 24-hour post-op craniotomy patient is reporting a headache 8/10.
What is the next step for the nurse to take?
A. Perform a neuro assessment
B. Administer the prescribed analgesic immediately
C. Document the finding and continue monitoring
D. Elevate the head of the bed to 90 degrees
Answer: A
Rationale: The nurse should first perform a neurological assessment to
determine if the headache is related to increased ICP or another
complication before administering medication.
10. Which clinical manifestation is a hallmark sign of the 'emergent
phase' of burn shock?
A. Increased blood pressure and heart rate
B. Decreased capillary refill and cool extremities
C. Hypertension and bradycardia
D. Polyuria and increased thirst
Answer: B
Rationale: The emergent phase of burn shock is characterized by
hypovolemia, decreased cardiac output, and poor tissue perfusion,
leading to decreased capillary refill and cool extremities.
11. A patient arrives at the emergency department with burns to the entire
left arm and the anterior trunk. Using the Rule of Nines, what percentage
