NUR 265 Exam 3 – Questions and
Answers (2026 Update) 100% Correct –
Galen College
EXAM 3
Question 1
The nurse is caring for an adult client who was recently admitted with a head
injury following a motor vehicle crash. One hour ago, the client’s vital signs were:
T 98.6°F, P 110, R 26, BP 128/68 mm Hg. Which of the following findings is a
priority for the nurse to follow up?
A. P: 90; R: 32; BP: 130/72 mm Hg
B. P: 120; R: 26; BP: 110/70 mm Hg
C. P: 56; R: 14; BP: 166/52 mm Hg
D. P: 64; R: 30; BP: 148/78 mm Hg
Correct Answer: C
Question 2
The nurse is caring for a client who sustained a closed head injury, is receiving
mechanical ventilation, and is at risk for developing increased intracranial
pressure (ICP). Which of the following actions should the nurse take when caring
for this client?
A. Perform passive range of motion (ROM) to the client’s hips and knees
B. Log roll the client during turning and repositioning
, C. Elevate the foot of the client’s bed
D. Notify the charge nurse if the client’s PaCO₂ decreases from 35 to 25 mm Hg
Correct Answer: B
Question 3
The newly hired nurse is caring for a client admitted 12 hours ago with a traumatic
brain injury (TBI), who is intubated and at risk for increased intracranial pressure
(ICP). Which interventions should the nurse include in the client’s plan of care?
A. 1, 3, 4, 5
B. 1, 3, 5, 6
C. 1, 2, 4, 6
D. 2, 4, 5, 6
Interventions:
1. Avoid clustering client care activities
2. Maintain the head in a flexed position
3. Provide a quiet environment by limiting visitors
4. Have the client cough and deep breathe every hour
5. Hyperoxygenate the client before and after suctioning
6. Avoid maintaining hips in a flexed position
Correct Answer: B
Question 4
The nurse in the ICU is assessing a client who sustained a basilar skull fracture 24
hours ago. It is most important to follow up with the primary health care provider
if the client:
Answers (2026 Update) 100% Correct –
Galen College
EXAM 3
Question 1
The nurse is caring for an adult client who was recently admitted with a head
injury following a motor vehicle crash. One hour ago, the client’s vital signs were:
T 98.6°F, P 110, R 26, BP 128/68 mm Hg. Which of the following findings is a
priority for the nurse to follow up?
A. P: 90; R: 32; BP: 130/72 mm Hg
B. P: 120; R: 26; BP: 110/70 mm Hg
C. P: 56; R: 14; BP: 166/52 mm Hg
D. P: 64; R: 30; BP: 148/78 mm Hg
Correct Answer: C
Question 2
The nurse is caring for a client who sustained a closed head injury, is receiving
mechanical ventilation, and is at risk for developing increased intracranial
pressure (ICP). Which of the following actions should the nurse take when caring
for this client?
A. Perform passive range of motion (ROM) to the client’s hips and knees
B. Log roll the client during turning and repositioning
, C. Elevate the foot of the client’s bed
D. Notify the charge nurse if the client’s PaCO₂ decreases from 35 to 25 mm Hg
Correct Answer: B
Question 3
The newly hired nurse is caring for a client admitted 12 hours ago with a traumatic
brain injury (TBI), who is intubated and at risk for increased intracranial pressure
(ICP). Which interventions should the nurse include in the client’s plan of care?
A. 1, 3, 4, 5
B. 1, 3, 5, 6
C. 1, 2, 4, 6
D. 2, 4, 5, 6
Interventions:
1. Avoid clustering client care activities
2. Maintain the head in a flexed position
3. Provide a quiet environment by limiting visitors
4. Have the client cough and deep breathe every hour
5. Hyperoxygenate the client before and after suctioning
6. Avoid maintaining hips in a flexed position
Correct Answer: B
Question 4
The nurse in the ICU is assessing a client who sustained a basilar skull fracture 24
hours ago. It is most important to follow up with the primary health care provider
if the client:
