NUR 265 Exam 3 Advanced Med-Surg
Questions And Well Graded Solutions With
Rationales Updated 2026-2027
Master your NUR 265 Exam 3 with this expert-compiled study guide containing comprehensive
practice questions and answers. Features direct test-ready coverage on Increased Intracranial
Pressure (IICP), Cushing's triad, spinal cord injuries, burns fluid calculations using the Parkland
formula, and shock management protocols. Every question includes detailed rationales to clarify
core clinical concepts and ensure immediate understanding. Perfect for boosting your advanced
med-surg exam scores.
1. Which assessment finding indicates that a patient with a traumatic brain injury is
experiencing Cushing's triad?
A) Tachycardia, hypotension, and tachypnea
B) Systolic hypertension, a widened pulse pressure, and bradycardia
C) Hypotension, muffled heart sounds, and jugular venous distention
D) Hyperpnea, pinpoint pupils, and decerebrate posturing
Rationale: Cushing's triad is a late sign of increased intracranial pressure (IICP)
indicating brainstem herniation. It consists of an increased systolic blood pressure
(widening pulse pressure), bradycardia, and irregular respirations. Option A
describes hypovolemic shock, and Option C describes Beck's triad.
2. Which action must the nurse prioritize first when caring for a patient admitted
with suspected bacterial meningitis?
A) Administering the initial dose of IV broad-spectrum antibiotics
B) Placing the patient on droplet transmission precautions
C) Assisting the healthcare provider with a diagnostic lumbar puncture
D) Administering a prescribed scheduled dose of an anticonvulsant
Rationale: Safety and infection control are the highest priorities. The nurse must
isolate the patient using droplet precautions immediately to prevent the spread of
droplets before initiating diagnostic procedures or medical treatments.
3. A patient weighing 70 kg has sustained full-thickness burns over 30% of their
body. Using the Parkland formula (4 mL × kg × % TBSA), what is the correct fluid
infusion volume that the nurse must administer during the first 8 hours after the injury
occurs?
,A) 8,400 mL
B) 4,200 mL
C) 2,100 mL
D) 5,600 mL
Rationale: Total 24-hour fluid volume is 4 mL × 70 kg × 30 = 8,400 mL. The Parkland
formula requires half of this total volume to be infused during the first 8 hours
following injury: 8,400 mL ÷ 2 = 4,200 mL.
4. Which clinical manifestation should the nurse monitor for closely to distinguish
neurogenic shock from hypovolemic shock?
A) Cool, clammy skin
B) Severe hypotension
C) Altered level of consciousness
D) Bradycardia
Rationale: Neurogenic shock is caused by a loss of sympathetic nervous system
tone, resulting in a unique combination of hypotension accompanied by bradycardia.
Hypovolemic shock causes a compensatory sympathetic response, leading to
tachycardia rather than bradycardia.
5. A patient with a cervical spinal cord injury suddenly reports a severe,
throbbing headache, and the nurse notes a blood pressure of 190/100 mmHg. Which
action should the nurse implement first?
A) Elevate the head of the bed to a high-Fowler's position
B) Palpate the bladder to check for urinary retention
C) Administer the prescribed PRN intravenous antihypertensive medication
D) Check the patient's rectum for fecal impaction
Rationale: The patient is experiencing autonomic dysreflexia, an emergency. The
immediate first action is to elevate the head of the bed to 90 degrees (high-Fowler's)
to cause an orthostatic reduction in blood pressure, before assessing for triggers like
bladder distention or fecal impaction.
6. Which medication should the nurse anticipate administering to a patient with
increased intracranial pressure (IICP) to pull fluid directly from the brain tissue into
the blood vessels?
A) Mannitol 20% intravenously
B) Methylprednisolone intravenously
C) Hydrochlorothiazide orally
D) Furosemide intravenously
,Rationale: Mannitol is an osmotic diuretic that increases osmotic pressure in the
plasma, drawing water out of the edematous brain tissue and into the vascular space
to reduce ICP. It requires an in-line filter for administration.
7. The nurse is caring for a patient who has transitioned into the progressive
stage of hypovolemic shock. Which laboratory value should the nurse monitor as the
primary indicator of anaerobic metabolism and cellular hypoxia?
A) Elevated blood urea nitrogen (BUN)
B) Elevated serum lactate level
C) Decreased arterial oxygen saturation (SaO2)
D) Decreased serum bicarbonate level
Rationale: As shock progresses, lack of oxygen forces cells into anaerobic
metabolism. This process produces lactic acid as a byproduct. An elevated serum
lactate level (typically >2.0 mmol/L) is the definitive marker of cellular hypoxia.
8. A patient presents to the emergency department with ascending muscle
weakness that began in the lower extremities and is moving upward. Which
assessment must the nurse prioritize above all others?
A) Deep tendon reflexes
B) Respiratory effort and vital capacity
C) Peripheral pulse intensity
D) Cranial nerve functions
Rationale: The patient is exhibiting classic symptoms of Guillain-Barré syndrome. As
the paralysis ascends, it can paralyze the diaphragm and intercostal muscles.
Monitoring respiratory rate, rhythm, effort, and vital capacity is the top priority to
identify impending respiratory failure.
9. A nurse is caring for a patient with Myasthenia Gravis who is experiencing
severe muscle weakness and respiratory distress. Which diagnostic test does the
nurse anticipate the provider will order to distinguish between a myasthenic crisis
and a cholinergic crisis?
A) The Edrophonium (Tensilon) test
B) Electromyography (EMG)
C) Serum acetylcholine receptor antibody assay
D) A lumbar puncture for CSF analysis
Rationale: The Tensilon test is used to differentiate the two crises. Edrophonium is a
short-acting acetylcholinesterase inhibitor. If muscle strength improves, the patient is
in a myasthenic crisis (undermedication). If weakness worsens or does not improve,
it is a cholinergic crisis (overmedication).
, 10. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22
mmHg and a mean arterial pressure (MAP) of 65 mmHg. What is this patient's
cerebral perfusion pressure (CPP), and how should the nurse interpret it?
A) 87 mmHg; the perfusion pressure is optimal.
B) 43 mmHg; the perfusion pressure is optimal.
C) 43 mmHg; the perfusion pressure is dangerously low.
D) 87 mmHg; the perfusion pressure is dangerously low.
Rationale: CPP is calculated as MAP minus ICP (
). Normal CPP is 70 to 100 mmHg. A CPP below 50 mmHg indicates critical
ischemia and brain hypoperfusion, making this a critical medical emergency.
11. During the emergent phase of a major burn injury, which electrolyte imbalance
does the nurse expect to find due to massive cellular destruction?
A) Hypokalemia
B) Hyperkalemia
C) Hyponatremia
D) Hypercalcemia
Rationale: Intracellular fluid is rich in potassium. When cells are destroyed by
thermal injury, massive amounts of potassium leak into the extracellular fluid and
bloodstream, causing hyperkalemia during the first 24 to 48 hours.
12. A patient is admitted with a diagnosis of rule-out encephalitis. Which
diagnostic procedure does the nurse prepare the patient for as the definitive method
to confirm this diagnosis?
A) Electroencephalogram (EEG)
B) Lumbar puncture for cerebrospinal fluid (CSF) analysis
C) Computed Tomography (CT) scan of the head with contrast
D) Magnetic Resonance Imaging (MRI) of the brain
Rationale: A lumbar puncture allows for the evaluation of CSF, which will show
specific viral or bacterial markers, elevated protein, and normal or altered glucose
levels, providing the definitive diagnosis for central nervous system infections like
encephalitis or meningitis.
Questions And Well Graded Solutions With
Rationales Updated 2026-2027
Master your NUR 265 Exam 3 with this expert-compiled study guide containing comprehensive
practice questions and answers. Features direct test-ready coverage on Increased Intracranial
Pressure (IICP), Cushing's triad, spinal cord injuries, burns fluid calculations using the Parkland
formula, and shock management protocols. Every question includes detailed rationales to clarify
core clinical concepts and ensure immediate understanding. Perfect for boosting your advanced
med-surg exam scores.
1. Which assessment finding indicates that a patient with a traumatic brain injury is
experiencing Cushing's triad?
A) Tachycardia, hypotension, and tachypnea
B) Systolic hypertension, a widened pulse pressure, and bradycardia
C) Hypotension, muffled heart sounds, and jugular venous distention
D) Hyperpnea, pinpoint pupils, and decerebrate posturing
Rationale: Cushing's triad is a late sign of increased intracranial pressure (IICP)
indicating brainstem herniation. It consists of an increased systolic blood pressure
(widening pulse pressure), bradycardia, and irregular respirations. Option A
describes hypovolemic shock, and Option C describes Beck's triad.
2. Which action must the nurse prioritize first when caring for a patient admitted
with suspected bacterial meningitis?
A) Administering the initial dose of IV broad-spectrum antibiotics
B) Placing the patient on droplet transmission precautions
C) Assisting the healthcare provider with a diagnostic lumbar puncture
D) Administering a prescribed scheduled dose of an anticonvulsant
Rationale: Safety and infection control are the highest priorities. The nurse must
isolate the patient using droplet precautions immediately to prevent the spread of
droplets before initiating diagnostic procedures or medical treatments.
3. A patient weighing 70 kg has sustained full-thickness burns over 30% of their
body. Using the Parkland formula (4 mL × kg × % TBSA), what is the correct fluid
infusion volume that the nurse must administer during the first 8 hours after the injury
occurs?
,A) 8,400 mL
B) 4,200 mL
C) 2,100 mL
D) 5,600 mL
Rationale: Total 24-hour fluid volume is 4 mL × 70 kg × 30 = 8,400 mL. The Parkland
formula requires half of this total volume to be infused during the first 8 hours
following injury: 8,400 mL ÷ 2 = 4,200 mL.
4. Which clinical manifestation should the nurse monitor for closely to distinguish
neurogenic shock from hypovolemic shock?
A) Cool, clammy skin
B) Severe hypotension
C) Altered level of consciousness
D) Bradycardia
Rationale: Neurogenic shock is caused by a loss of sympathetic nervous system
tone, resulting in a unique combination of hypotension accompanied by bradycardia.
Hypovolemic shock causes a compensatory sympathetic response, leading to
tachycardia rather than bradycardia.
5. A patient with a cervical spinal cord injury suddenly reports a severe,
throbbing headache, and the nurse notes a blood pressure of 190/100 mmHg. Which
action should the nurse implement first?
A) Elevate the head of the bed to a high-Fowler's position
B) Palpate the bladder to check for urinary retention
C) Administer the prescribed PRN intravenous antihypertensive medication
D) Check the patient's rectum for fecal impaction
Rationale: The patient is experiencing autonomic dysreflexia, an emergency. The
immediate first action is to elevate the head of the bed to 90 degrees (high-Fowler's)
to cause an orthostatic reduction in blood pressure, before assessing for triggers like
bladder distention or fecal impaction.
6. Which medication should the nurse anticipate administering to a patient with
increased intracranial pressure (IICP) to pull fluid directly from the brain tissue into
the blood vessels?
A) Mannitol 20% intravenously
B) Methylprednisolone intravenously
C) Hydrochlorothiazide orally
D) Furosemide intravenously
,Rationale: Mannitol is an osmotic diuretic that increases osmotic pressure in the
plasma, drawing water out of the edematous brain tissue and into the vascular space
to reduce ICP. It requires an in-line filter for administration.
7. The nurse is caring for a patient who has transitioned into the progressive
stage of hypovolemic shock. Which laboratory value should the nurse monitor as the
primary indicator of anaerobic metabolism and cellular hypoxia?
A) Elevated blood urea nitrogen (BUN)
B) Elevated serum lactate level
C) Decreased arterial oxygen saturation (SaO2)
D) Decreased serum bicarbonate level
Rationale: As shock progresses, lack of oxygen forces cells into anaerobic
metabolism. This process produces lactic acid as a byproduct. An elevated serum
lactate level (typically >2.0 mmol/L) is the definitive marker of cellular hypoxia.
8. A patient presents to the emergency department with ascending muscle
weakness that began in the lower extremities and is moving upward. Which
assessment must the nurse prioritize above all others?
A) Deep tendon reflexes
B) Respiratory effort and vital capacity
C) Peripheral pulse intensity
D) Cranial nerve functions
Rationale: The patient is exhibiting classic symptoms of Guillain-Barré syndrome. As
the paralysis ascends, it can paralyze the diaphragm and intercostal muscles.
Monitoring respiratory rate, rhythm, effort, and vital capacity is the top priority to
identify impending respiratory failure.
9. A nurse is caring for a patient with Myasthenia Gravis who is experiencing
severe muscle weakness and respiratory distress. Which diagnostic test does the
nurse anticipate the provider will order to distinguish between a myasthenic crisis
and a cholinergic crisis?
A) The Edrophonium (Tensilon) test
B) Electromyography (EMG)
C) Serum acetylcholine receptor antibody assay
D) A lumbar puncture for CSF analysis
Rationale: The Tensilon test is used to differentiate the two crises. Edrophonium is a
short-acting acetylcholinesterase inhibitor. If muscle strength improves, the patient is
in a myasthenic crisis (undermedication). If weakness worsens or does not improve,
it is a cholinergic crisis (overmedication).
, 10. A patient with a traumatic brain injury has an intracranial pressure (ICP) of 22
mmHg and a mean arterial pressure (MAP) of 65 mmHg. What is this patient's
cerebral perfusion pressure (CPP), and how should the nurse interpret it?
A) 87 mmHg; the perfusion pressure is optimal.
B) 43 mmHg; the perfusion pressure is optimal.
C) 43 mmHg; the perfusion pressure is dangerously low.
D) 87 mmHg; the perfusion pressure is dangerously low.
Rationale: CPP is calculated as MAP minus ICP (
). Normal CPP is 70 to 100 mmHg. A CPP below 50 mmHg indicates critical
ischemia and brain hypoperfusion, making this a critical medical emergency.
11. During the emergent phase of a major burn injury, which electrolyte imbalance
does the nurse expect to find due to massive cellular destruction?
A) Hypokalemia
B) Hyperkalemia
C) Hyponatremia
D) Hypercalcemia
Rationale: Intracellular fluid is rich in potassium. When cells are destroyed by
thermal injury, massive amounts of potassium leak into the extracellular fluid and
bloodstream, causing hyperkalemia during the first 24 to 48 hours.
12. A patient is admitted with a diagnosis of rule-out encephalitis. Which
diagnostic procedure does the nurse prepare the patient for as the definitive method
to confirm this diagnosis?
A) Electroencephalogram (EEG)
B) Lumbar puncture for cerebrospinal fluid (CSF) analysis
C) Computed Tomography (CT) scan of the head with contrast
D) Magnetic Resonance Imaging (MRI) of the brain
Rationale: A lumbar puncture allows for the evaluation of CSF, which will show
specific viral or bacterial markers, elevated protein, and normal or altered glucose
levels, providing the definitive diagnosis for central nervous system infections like
encephalitis or meningitis.
