NUR 265 EXAM 3 (GALEN) NEWEST 2025 TEST BANK|
NUR256 ADVANCED CONCEPTS OF MEDICAL
SURGICAL NURSING EXAM 3 REVIEW WITH 400 REAL
EXAM QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) ALREADY GRADED A+ (MOST
RECENT!!)
1. A client with a left-sided ischemic stroke has a blood
pressure of 190/100 mm Hg. Which order should the nurse
question?
A. Administer IV tPA if onset <4.5 hours
B. Lower BP to 140/90 mm Hg immediately
C. Obtain non-contrast CT scan
D. Elevate HOB to 30 degrees
Rationale: B – Rapid BP lowering reduces cerebral perfusion
pressure and may enlarge the infarct zone. BP is managed per
guidelines: treat only if >220/120 or if tPA candidate (then
goal <185/110 before tPA).
2. A client with a T6 spinal cord injury suddenly develops a
severe headache, nasal congestion, and profuse sweating. BP
1
,is 210/110 mm Hg, HR 48 bpm. What is the priority action?
A. Administer nitroglycerin SL
B. Place client in supine position
C. Raise head of bed and check for distended bladder
D. Prepare for endotracheal intubation
Rationale: C – Autonomic dysreflexia (noxious stimulus below
injury). Immediate: sit client upright (HOB 45–90°) to lower BP,
then identify stimulus (full bladder most common, then fecal
impaction).
3. Which finding 6 hours after a carotid endarterectomy
requires immediate intervention?
A. BP 145/85 mm Hg
B. Hoarse voice
C. Small amount of serous drainage on dressing
D. Sudden neck swelling and difficulty swallowing
Rationale: D – Sudden neck swelling + dysphagia suggests
hematoma with airway compression (surgical emergency).
Hoarseness (cranial nerve injury) is a complication but not
immediately life-threatening.
2
,4. A client with increased ICP has a new ICP reading of 32
mm Hg. Which intervention should the nurse perform first?
A. Administer mannitol IV push
B. Notify the provider
C. Check endotracheal tube cuff pressure
D. Drain CSF via ventriculostomy
Rationale: C – Priority is to correct reversible causes: ensure ETT
cuff not impeding jugular return, HOB 30°, neck midline, avoid
noxious stimuli. Mannitol and CSF drainage follow.
5. A client with status epilepticus has received IV lorazepam.
Seizures continue after 10 minutes. What should the nurse
prepare next?
A. Phenytoin IV push
B. Fosphenytoin IV infusion
C. Propofol drip
D. Levetiracetam PO
Rationale: B – After benzodiazepines, next-line is fosphenytoin
or phenytoin (IV infusion, not push due to cardiac risk). Propofol
used for refractory status epilepticus in ICU.
3
, 6. A client with myasthenia gravis reports increased
weakness and difficulty swallowing. What is the priority
assessment?
A. Pupil size and reactivity
B. Respiratory rate and depth
C. Grip strength
D. Deep tendon reflexes
Rationale: B – Swallowing difficulty → aspiration risk; weakness
can progress to myasthenic crisis with respiratory failure. Assess
airway/breathing first.
7. Which clinical manifestation differentiates Guillain-Barré
syndrome from a spinal cord injury?
A. Ascending flaccid paralysis
B. Loss of deep tendon reflexes
C. Bowel and bladder dysfunction
D. Symmetric weakness starting in lower extremities
Rationale: C – Bowel/bladder dysfunction is common in spinal
cord injury but usually spared in Guillain-Barré. Both have
ascending weakness and areflexia.
4
NUR256 ADVANCED CONCEPTS OF MEDICAL
SURGICAL NURSING EXAM 3 REVIEW WITH 400 REAL
EXAM QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) ALREADY GRADED A+ (MOST
RECENT!!)
1. A client with a left-sided ischemic stroke has a blood
pressure of 190/100 mm Hg. Which order should the nurse
question?
A. Administer IV tPA if onset <4.5 hours
B. Lower BP to 140/90 mm Hg immediately
C. Obtain non-contrast CT scan
D. Elevate HOB to 30 degrees
Rationale: B – Rapid BP lowering reduces cerebral perfusion
pressure and may enlarge the infarct zone. BP is managed per
guidelines: treat only if >220/120 or if tPA candidate (then
goal <185/110 before tPA).
2. A client with a T6 spinal cord injury suddenly develops a
severe headache, nasal congestion, and profuse sweating. BP
1
,is 210/110 mm Hg, HR 48 bpm. What is the priority action?
A. Administer nitroglycerin SL
B. Place client in supine position
C. Raise head of bed and check for distended bladder
D. Prepare for endotracheal intubation
Rationale: C – Autonomic dysreflexia (noxious stimulus below
injury). Immediate: sit client upright (HOB 45–90°) to lower BP,
then identify stimulus (full bladder most common, then fecal
impaction).
3. Which finding 6 hours after a carotid endarterectomy
requires immediate intervention?
A. BP 145/85 mm Hg
B. Hoarse voice
C. Small amount of serous drainage on dressing
D. Sudden neck swelling and difficulty swallowing
Rationale: D – Sudden neck swelling + dysphagia suggests
hematoma with airway compression (surgical emergency).
Hoarseness (cranial nerve injury) is a complication but not
immediately life-threatening.
2
,4. A client with increased ICP has a new ICP reading of 32
mm Hg. Which intervention should the nurse perform first?
A. Administer mannitol IV push
B. Notify the provider
C. Check endotracheal tube cuff pressure
D. Drain CSF via ventriculostomy
Rationale: C – Priority is to correct reversible causes: ensure ETT
cuff not impeding jugular return, HOB 30°, neck midline, avoid
noxious stimuli. Mannitol and CSF drainage follow.
5. A client with status epilepticus has received IV lorazepam.
Seizures continue after 10 minutes. What should the nurse
prepare next?
A. Phenytoin IV push
B. Fosphenytoin IV infusion
C. Propofol drip
D. Levetiracetam PO
Rationale: B – After benzodiazepines, next-line is fosphenytoin
or phenytoin (IV infusion, not push due to cardiac risk). Propofol
used for refractory status epilepticus in ICU.
3
, 6. A client with myasthenia gravis reports increased
weakness and difficulty swallowing. What is the priority
assessment?
A. Pupil size and reactivity
B. Respiratory rate and depth
C. Grip strength
D. Deep tendon reflexes
Rationale: B – Swallowing difficulty → aspiration risk; weakness
can progress to myasthenic crisis with respiratory failure. Assess
airway/breathing first.
7. Which clinical manifestation differentiates Guillain-Barré
syndrome from a spinal cord injury?
A. Ascending flaccid paralysis
B. Loss of deep tendon reflexes
C. Bowel and bladder dysfunction
D. Symmetric weakness starting in lower extremities
Rationale: C – Bowel/bladder dysfunction is common in spinal
cord injury but usually spared in Guillain-Barré. Both have
ascending weakness and areflexia.
4
