1|Page
Advanced Medical-Surgical Nursing Exam Study
Guide||Verified Exam!!!||, Jersey College School of
Nursing, 2026/2027-Question NGN-Aligned Adult
Health Assessment with Evidence-Based
Rationales||Newest Exam!!!
The nurse is caring for a client treated with alteplase
following a stroke. Which assessment finding is the
highest priority for the nurse to report to the primary health
care provider?
A. Client has a new-onset mild headache.
B. Client's blood pressure is 194/120 mm Hg.
C. Client has left hemiparesis.
D. Client continues to be drowsy. - Answer-Answer: B
Rational: Elevation in BP is the priority finding when
administering alteplase because of the risk for
hemorrhagic stroke
A nurse has just discontinued alteplase secondary to
blood pressure elevation of 201/108. The nurse promptly
notifies the provider and should anticipate what medication
to treat the severe HTN?
A. Labetalol
,2|Page
B. Dopamine
C. Dobutamine
D. Norepinephrine - Answer-Answer: A
Rational: Labetalol is a beta blocker and works by relaxing
blood vessels and slowing the HR which decreases blood
pressure. B, C, and D will have an inotropic effect on the
heart which will increase BP
During alteplase administration the nurse should monitor
the BP every __________ mins during the infusion
followed by every ___________ mins for _________
hours? (open response) - Answer-Answer: The nurse
should monitor the BP q 10-15 minutes during the infusion
followed by q 30 minutes for 6 hours after the infusion
A nurse is assessing a patient 48 hours post stroke. The
nurse is monitoring for an increase in ICP during this time.
What clinical manifestation would the nurse suspect to
appear FIRST if the patient were to have an increase in
ICP?
A. Severe HA
B. Constricted, non reactive pupils
C. Severe HTN
,3|Page
D. Decrease in LOC - Answer-Answer: D
Rational: A decrease in LOC is the first sign of increased
ICP. This should promptly be reported to the HCP. B, C, D
are late clinical manifestations of increase in ICP.
A nurse is taking care of a patient named Tim. He is post
48 hours following a stroke. The nurse goes into the room
and he is restless and irritable. He is confused and is
exhibiting signs of aphasia and dysarthria. The nurse
takes Tim's BP and it is 210/84 and his HR is 44. The
nurse should suspect what is happening? What specific
clinical manifestation is presenting with Tim? (open
response) - Answer-Answer: Tim is experiencing an
increase in ICP based on this confusion, decrease in LOC,
and signs of aphasia and dysarthria. In addition to this
Tim's severe HTN, widened pulse pressure, and
bradycardia is the clinical manifestation of Cushings triad,
a late sign of increased ICP.
Tim is a patient 48 hours post stroke and has developed
an increase in ICP. You the nurse are modifying the plan of
care to decrease Tim's ICP. What interventions should the
nurse add in this plan of care? (sata)
A. Position the HOB at 10 degrees
, 4|Page
B. Maintain the patients head midline and implement log
rolling to turn Tim
C. The nurse plans to administer medications and have
the CNA give the patient a bed bath and linen change right
after
D. Dim the room lights and maintain a quiet environment
E. Administer prescribed stool softeners
F. Suction the patients oral cavity - Answer-Answers: B, D,
and E
Rational: The nurse should position the HOB at 30
degrees, maintain a neutral position of the head,
administer 02 to keep saturation above 95%, should not
cluster care and should space it out, keep the room dimly
lit and quiet, administer stool softeners to prevent
straining, and never suction the patient unless absolutely
necessary. The nurse should assess the need for
suctioning and if need should hyperoxygenate prior to
suctioning.
A nurse is taking care of patient that is 24 hours post
stroke and is monitoring for increased ICP. Which clinical
manifestations are LATE signs of an increase in ICP?
(sata)
A. Severe HA
Advanced Medical-Surgical Nursing Exam Study
Guide||Verified Exam!!!||, Jersey College School of
Nursing, 2026/2027-Question NGN-Aligned Adult
Health Assessment with Evidence-Based
Rationales||Newest Exam!!!
The nurse is caring for a client treated with alteplase
following a stroke. Which assessment finding is the
highest priority for the nurse to report to the primary health
care provider?
A. Client has a new-onset mild headache.
B. Client's blood pressure is 194/120 mm Hg.
C. Client has left hemiparesis.
D. Client continues to be drowsy. - Answer-Answer: B
Rational: Elevation in BP is the priority finding when
administering alteplase because of the risk for
hemorrhagic stroke
A nurse has just discontinued alteplase secondary to
blood pressure elevation of 201/108. The nurse promptly
notifies the provider and should anticipate what medication
to treat the severe HTN?
A. Labetalol
,2|Page
B. Dopamine
C. Dobutamine
D. Norepinephrine - Answer-Answer: A
Rational: Labetalol is a beta blocker and works by relaxing
blood vessels and slowing the HR which decreases blood
pressure. B, C, and D will have an inotropic effect on the
heart which will increase BP
During alteplase administration the nurse should monitor
the BP every __________ mins during the infusion
followed by every ___________ mins for _________
hours? (open response) - Answer-Answer: The nurse
should monitor the BP q 10-15 minutes during the infusion
followed by q 30 minutes for 6 hours after the infusion
A nurse is assessing a patient 48 hours post stroke. The
nurse is monitoring for an increase in ICP during this time.
What clinical manifestation would the nurse suspect to
appear FIRST if the patient were to have an increase in
ICP?
A. Severe HA
B. Constricted, non reactive pupils
C. Severe HTN
,3|Page
D. Decrease in LOC - Answer-Answer: D
Rational: A decrease in LOC is the first sign of increased
ICP. This should promptly be reported to the HCP. B, C, D
are late clinical manifestations of increase in ICP.
A nurse is taking care of a patient named Tim. He is post
48 hours following a stroke. The nurse goes into the room
and he is restless and irritable. He is confused and is
exhibiting signs of aphasia and dysarthria. The nurse
takes Tim's BP and it is 210/84 and his HR is 44. The
nurse should suspect what is happening? What specific
clinical manifestation is presenting with Tim? (open
response) - Answer-Answer: Tim is experiencing an
increase in ICP based on this confusion, decrease in LOC,
and signs of aphasia and dysarthria. In addition to this
Tim's severe HTN, widened pulse pressure, and
bradycardia is the clinical manifestation of Cushings triad,
a late sign of increased ICP.
Tim is a patient 48 hours post stroke and has developed
an increase in ICP. You the nurse are modifying the plan of
care to decrease Tim's ICP. What interventions should the
nurse add in this plan of care? (sata)
A. Position the HOB at 10 degrees
, 4|Page
B. Maintain the patients head midline and implement log
rolling to turn Tim
C. The nurse plans to administer medications and have
the CNA give the patient a bed bath and linen change right
after
D. Dim the room lights and maintain a quiet environment
E. Administer prescribed stool softeners
F. Suction the patients oral cavity - Answer-Answers: B, D,
and E
Rational: The nurse should position the HOB at 30
degrees, maintain a neutral position of the head,
administer 02 to keep saturation above 95%, should not
cluster care and should space it out, keep the room dimly
lit and quiet, administer stool softeners to prevent
straining, and never suction the patient unless absolutely
necessary. The nurse should assess the need for
suctioning and if need should hyperoxygenate prior to
suctioning.
A nurse is taking care of patient that is 24 hours post
stroke and is monitoring for increased ICP. Which clinical
manifestations are LATE signs of an increase in ICP?
(sata)
A. Severe HA
