NUR 265 EXAM 3
Question Bank 50 Questions with complete
solutions | Latest 2026| Rated A
THIS DOCUMENT CONTAINS:
➢ GUARANTEE PASSING SCORE
➢ QUESTIONS AND ANSWERS
➢ EXPERT VERIFIED EXPLANATIONS
➢ FORMAT SET OF MULTIPLE-CHOICE
, Topic 1: Traumatic Brain Injury (TBI) & Increased ICP
(Questions 1–15)
1. A client with a severe TBI has an ICP monitor in place. The nurse notes an ICP
of 22 mm Hg sustained for 10 minutes. What is the nurse's priority action?
• A. Administer prescribed mannitol
• B. Notify the healthcare provider immediately
• C. Elevate the head of the bed to 90 degrees
• D. Check the client's gag reflex
Correct Answer: B – Notify the healthcare provider immediately
Rationale: Normal ICP is 5–15 mm Hg; sustained ICP >20 mm Hg is critical and
requires immediate intervention to prevent herniation. Mannitol may be given, but
the provider must be notified first unless a PRN order exists. Head elevation should
be 30–45°, not 90°.
2. The nurse is assessing a client 6 hours after a craniotomy. Which finding
indicates possible increased ICP?
• A. Pupils equal and reactive to light
• B. Glasgow Coma Scale (GCS) score of 15
• C. Blood pressure 140/80, pulse 88
• D. Restlessness and confusion
Correct Answer: D – Restlessness and confusion
Rationale: Early signs of increased ICP include decreased level of consciousness,
restlessness, confusion, and irritability. Late signs include Cushing’s triad
(hypertension, bradycardia, irregular respirations) and pupillary changes.
3. A client with a TBI has a GCS score of 6. Which nursing intervention is most
appropriate?
• A. Encourage oral fluids
• B. Provide oral care with a toothbrush
• C. Maintain the head of bed flat
• D. Suction the airway as needed
, Correct Answer: D – Suction the airway as needed
Rationale: GCS ≤8 indicates severe brain injury and inability to protect airway.
Suctioning is essential to maintain airway patency. Oral care should use sponge
swabs, not toothbrushes (risk of gagging/ICP increase). HOB should be elevated.
4. The nurse is caring for a client with ICP monitoring. Which finding requires
immediate action?
• A. ICP 18 mm Hg for 5 minutes
• B. Cerebral perfusion pressure (CPP) 50 mm Hg
• C. Pulse oximetry 94%
• D. Urine output 40 mL/hr
Correct Answer: B – CPP 50 mm Hg
Rationale: CPP = MAP – ICP. Normal CPP is 60–100 mm Hg. CPP <60 indicates
inadequate cerebral blood flow and risk of brain ischemia. ICP 18 is borderline but
not critical alone.
5. Which position is contraindicated for a client with increased ICP?
• A. Head midline
• B. Head of bed at 30 degrees
• C. Neck flexed toward the chest
• D. Hips flexed at 90 degrees
Correct Answer: C – Neck flexed toward the chest
Rationale: Neck flexion compresses jugular veins, reducing venous drainage from
the brain and increasing ICP. The head should remain in a midline, neutral position.
6. The nurse administers mannitol IV to a client with increased ICP. Which
assessment finding indicates the medication is effective?
• A. Decreased serum osmolality
• B. Increased urine output
• C. Increased blood pressure
Question Bank 50 Questions with complete
solutions | Latest 2026| Rated A
THIS DOCUMENT CONTAINS:
➢ GUARANTEE PASSING SCORE
➢ QUESTIONS AND ANSWERS
➢ EXPERT VERIFIED EXPLANATIONS
➢ FORMAT SET OF MULTIPLE-CHOICE
, Topic 1: Traumatic Brain Injury (TBI) & Increased ICP
(Questions 1–15)
1. A client with a severe TBI has an ICP monitor in place. The nurse notes an ICP
of 22 mm Hg sustained for 10 minutes. What is the nurse's priority action?
• A. Administer prescribed mannitol
• B. Notify the healthcare provider immediately
• C. Elevate the head of the bed to 90 degrees
• D. Check the client's gag reflex
Correct Answer: B – Notify the healthcare provider immediately
Rationale: Normal ICP is 5–15 mm Hg; sustained ICP >20 mm Hg is critical and
requires immediate intervention to prevent herniation. Mannitol may be given, but
the provider must be notified first unless a PRN order exists. Head elevation should
be 30–45°, not 90°.
2. The nurse is assessing a client 6 hours after a craniotomy. Which finding
indicates possible increased ICP?
• A. Pupils equal and reactive to light
• B. Glasgow Coma Scale (GCS) score of 15
• C. Blood pressure 140/80, pulse 88
• D. Restlessness and confusion
Correct Answer: D – Restlessness and confusion
Rationale: Early signs of increased ICP include decreased level of consciousness,
restlessness, confusion, and irritability. Late signs include Cushing’s triad
(hypertension, bradycardia, irregular respirations) and pupillary changes.
3. A client with a TBI has a GCS score of 6. Which nursing intervention is most
appropriate?
• A. Encourage oral fluids
• B. Provide oral care with a toothbrush
• C. Maintain the head of bed flat
• D. Suction the airway as needed
, Correct Answer: D – Suction the airway as needed
Rationale: GCS ≤8 indicates severe brain injury and inability to protect airway.
Suctioning is essential to maintain airway patency. Oral care should use sponge
swabs, not toothbrushes (risk of gagging/ICP increase). HOB should be elevated.
4. The nurse is caring for a client with ICP monitoring. Which finding requires
immediate action?
• A. ICP 18 mm Hg for 5 minutes
• B. Cerebral perfusion pressure (CPP) 50 mm Hg
• C. Pulse oximetry 94%
• D. Urine output 40 mL/hr
Correct Answer: B – CPP 50 mm Hg
Rationale: CPP = MAP – ICP. Normal CPP is 60–100 mm Hg. CPP <60 indicates
inadequate cerebral blood flow and risk of brain ischemia. ICP 18 is borderline but
not critical alone.
5. Which position is contraindicated for a client with increased ICP?
• A. Head midline
• B. Head of bed at 30 degrees
• C. Neck flexed toward the chest
• D. Hips flexed at 90 degrees
Correct Answer: C – Neck flexed toward the chest
Rationale: Neck flexion compresses jugular veins, reducing venous drainage from
the brain and increasing ICP. The head should remain in a midline, neutral position.
6. The nurse administers mannitol IV to a client with increased ICP. Which
assessment finding indicates the medication is effective?
• A. Decreased serum osmolality
• B. Increased urine output
• C. Increased blood pressure
