NUR 265 Exam 3 Medical-Surgical Nursing (2026) PDF | Galen
College of Nursing with highlighted answers.
The nurse is provided teaching to a client who was just diagnosed with Bell's palsy. Which of the
following client statements requires follow up by the nurse?
I will need to take carbamazepine to control my symptoms
The nurse is caring for the following assigned clients. It would be appropriate for the nurse to
recommend a referral for evaluation for palliative care for the client who
has had ALS for the past 3 years and was recently admitted with pain, fatigue and difficulty
The nurse is discussing advanced directives with a client who has ALS. The client tells the nurse "I
don't want to be put on a breathing machine." Which of the following is an appropriate response by the
nurse?
What would you like to be done if you start to have difficulty breathing
The nurse has attended a CE conference on GB. Which of the following statements by the nurse
indicates a correct understanding of the conference?
the immune system reacts by destroying the myelin sheath
The nurse is assessing a client who has GB. The nurse notes diminished lung sounds, respirations
of 8 and shallow, and a pulse ox of 88%. Which of the following actions should the nurse take?
prepare the client fo r intubation
The nurse is caring for a male client who sustained full thickness burns on the back and posterior
legs six hours ago. Which of the following lab values would be an initial expected finding?
A serum sodium level of 128
The nurse is caring for a client who is burned and has developed drooling and difficulty
swallowing. Which of the following actions should the nurse first take?
Auscultate breath sounds over the trachea and mainstream bronchi
The nurse is caring for a client who sustained an electrical injury and was brought to the ED.
Which of the following nursing actions should the nurse take first?
place the client on continous cardiac monitoring
he nurse is caring for a client who suffered 33% TBSA 48hr ago. The nurse notes a gradual
increase in the client's urine output over the last 12 hrs. Which of the following actions would the nurse
1|Page
, take?
document the findings and continue to monitor the output
1.The nurse is working in the emergency department and is admitting a client who has a sustained TBI,
following a motor vehicle crash, it is a priority for the nurse to notify the primary health care provider if
the client
takes prescribed warfarin daily
The charge nurse observes a newly hired nurse caring for a client who sustained a closed head
injury, is receiving mechanical ventilation, and is at risk for developing ICP. Which of the following
actions, if performed by the newly hired nurse, requires intervention by the charge nurse?
raising the foot of the clients bed
The newly hired nurse is caring for a client who was admitted 12 hours ago with a TBI and is at risk
for developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed
Clustering client care activities
The nurse is assessing clients for the risk of sustaining TBI. Which of the following clients should
the nurse identify as being at greatest risk?
20 yr old college student who participates on the football team
The nurse is caring for assigned clients. Which of the following assessment findings requires the
nurse to notify the PHCP?
the development of asymmetric pupils with no reaction to light in the client who has the TBI
The nurse is caring for a client with a TBI and a skull fracture. The nurse noted that the client had
developed rhinorrhea (nasal drip) positive for glucose. Which of the following actions should the
nurse take next?
Perform a halo sign test
The nurse is providing discharge instructions to a client's partner who sustained a mild head
injury due to an MVA. Which of the following statements, if made by the partners, would indicate
the need for additional teaching?
i will bring my partner to the ED if they immediately starting vomiting
The nurse is caring for the following assigned clients. Which client should the nurse see first?
The client who has brain injusry and bp change from 110/58 to 134/40
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College of Nursing with highlighted answers.
The nurse is provided teaching to a client who was just diagnosed with Bell's palsy. Which of the
following client statements requires follow up by the nurse?
I will need to take carbamazepine to control my symptoms
The nurse is caring for the following assigned clients. It would be appropriate for the nurse to
recommend a referral for evaluation for palliative care for the client who
has had ALS for the past 3 years and was recently admitted with pain, fatigue and difficulty
The nurse is discussing advanced directives with a client who has ALS. The client tells the nurse "I
don't want to be put on a breathing machine." Which of the following is an appropriate response by the
nurse?
What would you like to be done if you start to have difficulty breathing
The nurse has attended a CE conference on GB. Which of the following statements by the nurse
indicates a correct understanding of the conference?
the immune system reacts by destroying the myelin sheath
The nurse is assessing a client who has GB. The nurse notes diminished lung sounds, respirations
of 8 and shallow, and a pulse ox of 88%. Which of the following actions should the nurse take?
prepare the client fo r intubation
The nurse is caring for a male client who sustained full thickness burns on the back and posterior
legs six hours ago. Which of the following lab values would be an initial expected finding?
A serum sodium level of 128
The nurse is caring for a client who is burned and has developed drooling and difficulty
swallowing. Which of the following actions should the nurse first take?
Auscultate breath sounds over the trachea and mainstream bronchi
The nurse is caring for a client who sustained an electrical injury and was brought to the ED.
Which of the following nursing actions should the nurse take first?
place the client on continous cardiac monitoring
he nurse is caring for a client who suffered 33% TBSA 48hr ago. The nurse notes a gradual
increase in the client's urine output over the last 12 hrs. Which of the following actions would the nurse
1|Page
, take?
document the findings and continue to monitor the output
1.The nurse is working in the emergency department and is admitting a client who has a sustained TBI,
following a motor vehicle crash, it is a priority for the nurse to notify the primary health care provider if
the client
takes prescribed warfarin daily
The charge nurse observes a newly hired nurse caring for a client who sustained a closed head
injury, is receiving mechanical ventilation, and is at risk for developing ICP. Which of the following
actions, if performed by the newly hired nurse, requires intervention by the charge nurse?
raising the foot of the clients bed
The newly hired nurse is caring for a client who was admitted 12 hours ago with a TBI and is at risk
for developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed
Clustering client care activities
The nurse is assessing clients for the risk of sustaining TBI. Which of the following clients should
the nurse identify as being at greatest risk?
20 yr old college student who participates on the football team
The nurse is caring for assigned clients. Which of the following assessment findings requires the
nurse to notify the PHCP?
the development of asymmetric pupils with no reaction to light in the client who has the TBI
The nurse is caring for a client with a TBI and a skull fracture. The nurse noted that the client had
developed rhinorrhea (nasal drip) positive for glucose. Which of the following actions should the
nurse take next?
Perform a halo sign test
The nurse is providing discharge instructions to a client's partner who sustained a mild head
injury due to an MVA. Which of the following statements, if made by the partners, would indicate
the need for additional teaching?
i will bring my partner to the ED if they immediately starting vomiting
The nurse is caring for the following assigned clients. Which client should the nurse see first?
The client who has brain injusry and bp change from 110/58 to 134/40
2|Page
