NUR 265 Exam 3 Medical-Surgical Nursing (2026) PDF |
Galen College of Nursing Graded A+(100 +QUESTIONS
WITH ANSWERS AND RATIONALES)
THIS EXAM INCLUDES:
• NUR 265 Exam 3
• Medical-Surgical Nursing (2026)
• Galen College of Nursing
• Graded A+
• 100+QUESTIONS
• ANSWERS WITH RATIONALES
, Traumatic Brain Injury (TBI) & Increased Intracranial Pressure (ICP)
x x x x x x x x x
This section covers the highest-priority concepts for Exam 3, including assessment
x x x x x x x x x x
of neurological decline and emergency interventions.
x x x x x x
Question 1: The nurse is caring for an adult client who was recently admitted with a
x x x x x x x x x x x x x x x
head injury following a motor vehicle crash. One hour ago, the client's vital signs
x x x x x x x x x x x x x x
(VS) were T: 98.6°F; P: 110; R: 26; BP: 128/68 mm Hg. Which of the following
x x x x x x x x x x x x x x x x
findings is a priority for the nurse to follow up?
x x x x x x x x x x
A) P: 90; R: 32; BP: 130/72 mm Hg
x x x x x x x x
B) P: 120; R: 26, BP: 110/70 mm Hg
x x x x x x x x
C) P: 56; R: 14; BP: 166/52 mm Hg
x x x x x x x x
D) P: 64, R: 30; BP: 148/78m Hg
x x x x x x x
Correct Answer: C x x
Rationale: The combination of bradycardia (P: 56) , hypertension (BP: 166/52) ,
x x x x x x x x x x x
and irregular respirations is Cushing's Triad, a late and ominous sign of significantly
x x x x x x x x x x x x x
increased intracranial pressure (ICP) and impending brain herniation. This is a
x x x x x x x x x x x
medical emergency requiring immediate intervention.
x x x x x
Question 2: The nurse is caring for a client who sustained a closed head injury, is
x x x x x x x x x x x x x x x
receiving mechanical ventilation, and is at risk for developing increased ICP. Which
x x x x x x x x x x x x
of the following actions should the nurse take when caring for this client?
x x x x x x x x x x x x x
A) Perform passive range of motion (ROM) to the client's hips and knees.
x x x x x x x x x x x x
B) Log roll the client during turning and repositioning.
x x x x x x x x
C) Elevate the foot of the client's bed.
x x x x x x x
D) Notify the charge nurse if the client's PaCO2, decreases from 39 to 35 mm Hg.
x x x x x x x x x x x x x x x
Correct Answer: B x x
Rationale: Maintaining spinal alignment is critical after a head injury. The client
x x x x x x x x x x x
should be log-rolled (turned as a unit with the head, neck, and spine aligned) to
x x x x x x x x x x x x x x x
prevent any twisting or flexion that could increase ICP or cause further spinal cord
x x x x x x x x x x x x x x
injury.
x
,Question 3: The nurse is providing discharge instructions to the parents of a 15-
x x x x x x x x x x x x x
year-old female who sustained a concussion while playing field hockey. Which of
x x x x x x x x x x x
the following statements by a parent indicates a need for further teaching?
x x x x x x x x x x x x
A) "We should avoid giving any acetaminophen to treat headaches."
x x x x x x x x x
B) "We need to bring our daughter back to the emergency department if she
x x x x x x x x x x x x x
exhibits blurred vision."
x x x
C) "We should provide a consistent routine at home to assist with any behavior
x x x x x x x x x x x x x
changes."
x
D) "We will not allow our daughter to engage in strenuous activity for at least 48
x x x x x x x x x x x x x x x
hours."
x
Correct Answer: A x x
Rationale: Acetaminophen (Tylenol) is the recommended analgesic for headaches
x x x x x x x x
following a concussion because it does not increase the risk of bleeding, unlike
x x x x x x x x x x x x x
NSAIDs (ibuprofen, naproxen) or aspirin. Complete avoidance of acetaminophen
x x x x x x x x x
indicates a misunderstanding of discharge instructions.
x x x x x x
Neurological Disorders (Meningitis, Myasthenia Gravis, Spinal Cord Injury)
x x x x x x x x
This section focuses on recognizing critical symptoms and initiating priority nursing
x x x x x x x x x x
actions for complex neuro conditions.
x x x x x
Question 4: The nurse working in the emergency department (ED) is admitting a
x x x x x x x x x x x x
client who is a college student and lives in a dormitory. The client has chills, nuchal
x x x x x x x x x x x x x x x x
rigidity, and a temperature (T) of 101.5° F. Which of the following actions should
x x x x x x x x x x x x x x
the nurse take first?
x x x x
A) Obtain a blood culture and start intravenous (IV) antibiotics
x x x x x x x x x
B) Administer antipyretics as prescribed
x x x x
C) Initiate droplet isolation precautions
x x x x
D) Measure the client's oxygen saturation
x x x x x
Correct Answer: C x x
Rationale: Bacterial meningitis is highly contagious and transmitted via respiratory
x x x x x x x x x
droplets. The priority action is to initiate droplet precautions immediately upon
x x x x x x x x x x x
, admission (before diagnostic confirmation) to protect staff, other patients, and
x x x x x x x x x x
visitors. Antibiotics are started after diagnostic tests (LP, blood cultures) are
x x x x x x x x x x x
obtained.
x
Question 5: The nurse is caring for a client who has myasthenia gravis (MG). The
x x x x x x x x x x x x x x
client reports increased muscle weakness and difficulty swallowing. Which of the
x x x x x x x x x x x
following actions should the nurse take first?
x x x x x x x
A) Administer the prescribed PRN laxative.
x x x x x
B) Assess the client's respiratory status and oxygen saturation.
x x x x x x x x
C) Prepare to administer atropine sulfate.
x x x x x
D) Hold the next dose of pyridostigmine.
x x x x x x
Correct Answer: B x x
Rationale: In a client with MG, worsening weakness and dysphagia signal a
x x x x x x x x x x x
potential myasthenic crisis. This can rapidly progress to respiratory failure. The
x x x x x x x x x x x
nurse's priority is to assess the airway and breathing (respiratory rate, oxygen
x x x x x x x x x x x x
saturation, lung sounds) to determine the need for immediate respiratory support.
x x x x x x x x x x x
Question 6: The nurse is caring for a client who has paraplegia and is being
x x x x x x x x x x x x x x
transferred to a rehabilitation facility. The client suddenly becomes flushed,
x x x x x x x x x x
reports a severe pounding headache, and has a blood pressure of 190/110 mm Hg.
x x x x x x x x x x x x x x
Which of the following actions should the nurse take first?
x x x x x x x x x x
A) Administer a prescribed PRN antihypertensive.
x x x x x
B) Check the client's indwelling urinary catheter for kinks or obstruction.
x x x x x x x x x x
C) Elevate the head of the bed to a high Fowler's position.
x x x x x x x x x x x
D) Notify the primary health care provider (PHCP).
x x x x x x x
Correct Answer: B x x
Rationale: These are classic signs of autonomic dysreflexia, a life-threatening
x x x x x x x x x
emergency in clients with spinal cord injuries at T6 or above. The most common
x x x x x x x x x x x x x x
cause is a distended bladder or bowel. The priority action is to identify and remove
x x x x x x x x x x x x x x x
the noxious stimulus—checking the catheter is the correct first step. Raising the
x x x x x x x x x x x x
HOB is also critical but follows the initial assessment for the cause.
x x x x x x x x x x x x
Galen College of Nursing Graded A+(100 +QUESTIONS
WITH ANSWERS AND RATIONALES)
THIS EXAM INCLUDES:
• NUR 265 Exam 3
• Medical-Surgical Nursing (2026)
• Galen College of Nursing
• Graded A+
• 100+QUESTIONS
• ANSWERS WITH RATIONALES
, Traumatic Brain Injury (TBI) & Increased Intracranial Pressure (ICP)
x x x x x x x x x
This section covers the highest-priority concepts for Exam 3, including assessment
x x x x x x x x x x
of neurological decline and emergency interventions.
x x x x x x
Question 1: The nurse is caring for an adult client who was recently admitted with a
x x x x x x x x x x x x x x x
head injury following a motor vehicle crash. One hour ago, the client's vital signs
x x x x x x x x x x x x x x
(VS) were T: 98.6°F; P: 110; R: 26; BP: 128/68 mm Hg. Which of the following
x x x x x x x x x x x x x x x x
findings is a priority for the nurse to follow up?
x x x x x x x x x x
A) P: 90; R: 32; BP: 130/72 mm Hg
x x x x x x x x
B) P: 120; R: 26, BP: 110/70 mm Hg
x x x x x x x x
C) P: 56; R: 14; BP: 166/52 mm Hg
x x x x x x x x
D) P: 64, R: 30; BP: 148/78m Hg
x x x x x x x
Correct Answer: C x x
Rationale: The combination of bradycardia (P: 56) , hypertension (BP: 166/52) ,
x x x x x x x x x x x
and irregular respirations is Cushing's Triad, a late and ominous sign of significantly
x x x x x x x x x x x x x
increased intracranial pressure (ICP) and impending brain herniation. This is a
x x x x x x x x x x x
medical emergency requiring immediate intervention.
x x x x x
Question 2: The nurse is caring for a client who sustained a closed head injury, is
x x x x x x x x x x x x x x x
receiving mechanical ventilation, and is at risk for developing increased ICP. Which
x x x x x x x x x x x x
of the following actions should the nurse take when caring for this client?
x x x x x x x x x x x x x
A) Perform passive range of motion (ROM) to the client's hips and knees.
x x x x x x x x x x x x
B) Log roll the client during turning and repositioning.
x x x x x x x x
C) Elevate the foot of the client's bed.
x x x x x x x
D) Notify the charge nurse if the client's PaCO2, decreases from 39 to 35 mm Hg.
x x x x x x x x x x x x x x x
Correct Answer: B x x
Rationale: Maintaining spinal alignment is critical after a head injury. The client
x x x x x x x x x x x
should be log-rolled (turned as a unit with the head, neck, and spine aligned) to
x x x x x x x x x x x x x x x
prevent any twisting or flexion that could increase ICP or cause further spinal cord
x x x x x x x x x x x x x x
injury.
x
,Question 3: The nurse is providing discharge instructions to the parents of a 15-
x x x x x x x x x x x x x
year-old female who sustained a concussion while playing field hockey. Which of
x x x x x x x x x x x
the following statements by a parent indicates a need for further teaching?
x x x x x x x x x x x x
A) "We should avoid giving any acetaminophen to treat headaches."
x x x x x x x x x
B) "We need to bring our daughter back to the emergency department if she
x x x x x x x x x x x x x
exhibits blurred vision."
x x x
C) "We should provide a consistent routine at home to assist with any behavior
x x x x x x x x x x x x x
changes."
x
D) "We will not allow our daughter to engage in strenuous activity for at least 48
x x x x x x x x x x x x x x x
hours."
x
Correct Answer: A x x
Rationale: Acetaminophen (Tylenol) is the recommended analgesic for headaches
x x x x x x x x
following a concussion because it does not increase the risk of bleeding, unlike
x x x x x x x x x x x x x
NSAIDs (ibuprofen, naproxen) or aspirin. Complete avoidance of acetaminophen
x x x x x x x x x
indicates a misunderstanding of discharge instructions.
x x x x x x
Neurological Disorders (Meningitis, Myasthenia Gravis, Spinal Cord Injury)
x x x x x x x x
This section focuses on recognizing critical symptoms and initiating priority nursing
x x x x x x x x x x
actions for complex neuro conditions.
x x x x x
Question 4: The nurse working in the emergency department (ED) is admitting a
x x x x x x x x x x x x
client who is a college student and lives in a dormitory. The client has chills, nuchal
x x x x x x x x x x x x x x x x
rigidity, and a temperature (T) of 101.5° F. Which of the following actions should
x x x x x x x x x x x x x x
the nurse take first?
x x x x
A) Obtain a blood culture and start intravenous (IV) antibiotics
x x x x x x x x x
B) Administer antipyretics as prescribed
x x x x
C) Initiate droplet isolation precautions
x x x x
D) Measure the client's oxygen saturation
x x x x x
Correct Answer: C x x
Rationale: Bacterial meningitis is highly contagious and transmitted via respiratory
x x x x x x x x x
droplets. The priority action is to initiate droplet precautions immediately upon
x x x x x x x x x x x
, admission (before diagnostic confirmation) to protect staff, other patients, and
x x x x x x x x x x
visitors. Antibiotics are started after diagnostic tests (LP, blood cultures) are
x x x x x x x x x x x
obtained.
x
Question 5: The nurse is caring for a client who has myasthenia gravis (MG). The
x x x x x x x x x x x x x x
client reports increased muscle weakness and difficulty swallowing. Which of the
x x x x x x x x x x x
following actions should the nurse take first?
x x x x x x x
A) Administer the prescribed PRN laxative.
x x x x x
B) Assess the client's respiratory status and oxygen saturation.
x x x x x x x x
C) Prepare to administer atropine sulfate.
x x x x x
D) Hold the next dose of pyridostigmine.
x x x x x x
Correct Answer: B x x
Rationale: In a client with MG, worsening weakness and dysphagia signal a
x x x x x x x x x x x
potential myasthenic crisis. This can rapidly progress to respiratory failure. The
x x x x x x x x x x x
nurse's priority is to assess the airway and breathing (respiratory rate, oxygen
x x x x x x x x x x x x
saturation, lung sounds) to determine the need for immediate respiratory support.
x x x x x x x x x x x
Question 6: The nurse is caring for a client who has paraplegia and is being
x x x x x x x x x x x x x x
transferred to a rehabilitation facility. The client suddenly becomes flushed,
x x x x x x x x x x
reports a severe pounding headache, and has a blood pressure of 190/110 mm Hg.
x x x x x x x x x x x x x x
Which of the following actions should the nurse take first?
x x x x x x x x x x
A) Administer a prescribed PRN antihypertensive.
x x x x x
B) Check the client's indwelling urinary catheter for kinks or obstruction.
x x x x x x x x x x
C) Elevate the head of the bed to a high Fowler's position.
x x x x x x x x x x x
D) Notify the primary health care provider (PHCP).
x x x x x x x
Correct Answer: B x x
Rationale: These are classic signs of autonomic dysreflexia, a life-threatening
x x x x x x x x x
emergency in clients with spinal cord injuries at T6 or above. The most common
x x x x x x x x x x x x x x
cause is a distended bladder or bowel. The priority action is to identify and remove
x x x x x x x x x x x x x x x
the noxious stimulus—checking the catheter is the correct first step. Raising the
x x x x x x x x x x x x
HOB is also critical but follows the initial assessment for the cause.
x x x x x x x x x x x x
