NUR 265 Practice Exam Questions
and Answers Updated Top Rated
#1: The nurse is working in the emergency department (ED) is admitting a client who has sustained a
traumatic brain injury (TBI) f ollowing a motor vehicle crash. It is priority f or the nurse to notif y the
primary healthcare provider (PHCP) in the client:
Takes prescribed warf arin daily.
RATIONALE: Pg. 2400. Hemorrhage may occur as part of the primary injury and begin at the moment
of impact. Warf arin is a blood thinner and the patient may bleed out if they have a hematoma (a
collection of blood)
#2: The charge nurse is observing a newly hired nurse care f or a client who sustained a closed head
injury, is receiving mechanical ventilation, and is at risk f or developing ICP. Which of the f ollowing
actions, if perf ormed by the newly hired nurse, requires intervention by the charge nurse?
Raising the f oot of the client’s bed.
RATIONALE: Pg. 2413. Maintain the head midline, neutral position to prevent increased ICP.
#3: The newly hired nurse is caring f or a client who was admitted 12 hours ago with a TBI and is at risk
f or developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed
Clustering client care activities
RATIONALE: pg. 2387. When multiple activities are clustered in a row, the ef f ect on ICP can be
dramatic elevation.
#4: The nurse is assessing clients f or the risk of sustaining TBI. Which of the f ollowing clients should
the nurse identif y as being at greatest risk?
20 year old college student who participates on the f ootball team.
RATIONALE: Pg. 2397. A f orce produce by a blow direct to the head can contribute to a brain injury.
#5: The nurse is caring f or assigned clients. Which of the f ollowing assessment f indings requires the
nurse to notif y the PHCP?
The development of asymmetric pupils with no reaction to light in the client who has a TBI.
RATIONALE: Pg. 2386. Pupillary changes; dilated and non reactive pupils “blown” or constrictive, non
reactive pupils.
#6: The nurse is caring f or a client who had a TBI with skull f racture. The nurse noted that the client has
developed rhinorrhea (nasal drip) that is positive f or glucose. Which of the f ollowing actions should the
nurse take next?
Perf orm a halo sign test.
RATIONALE: Pg. 2410. CSF leaking, lab test will be analyzed f or glucose and electrolyte content. Place
on a white absorbent paper or linen.
#7: The nurse is providing discharge instructions to the partner of a client who sustained a mild head
injury as a result of a MVA. Which of the f ollowing statements, if made by the partners would indicated
the need f or additional teaching?
I will bring my partner to the ED if they immediately starting vomiting.
RATIONALE: Pg. 2405. Symptoms usually resolve within 72 hrs. NV expected.
#8: The nurse is caring f or the f ollowing assigned clients. Which client should the nurse see f irst?
, The client who has a brain injury and a BP change f rom 110/58 to 134/40 mm Hg.
RATIONALE: Pg. 2386. Cushing Triad. Severe HTN, widened pulse pressure, bradycardia.
#9: The nurse is caring f or a client who is 24 hours post op f ollowing a craniotomy. The client is
reporting a headache that is rated as an 8 on a scale of 0-10 pain scale. Which of the f ollowing actions
should the nurse take?
, Perf orm a neurological test.
RATIONALE: Pg. 2430. Symptoms of increased ICP included servers headache, deteriorating LOC,
restlessness, and irritability.
#10: The nurse is caring f or a client who has encephalitis. It is priority f or the nurse to f ollow up if the
client
Has a change in BP f rom 120/78 to 130/60 mm Hg.
RATIONALE: Pg. 2256. Changes in VS that require immediate notif ication to the HCP are a widened
pulse pressure, new bradycardia, and irregular respiratory ef f ort.
#11: The nurse is caring f or a client who has been admitted with suspected bacterial meningitis. Which
of the f ollowing actions should the nurse take f irst?
Prepare the client f or a lumbar puncture.
RATIONALE: Pg. 2251. Most signif icant lab test to determine BM is testing of CSF with a lumbar
puncture. A broad spectrum antibiotic is given bef ore the lumbar puncture.
#12: The nurse is caring f or the client who has conf usion, f ever, headache, blurred vision, NV, and a
history of HIV. Which of the f ollowing actions should the nurse take f irst?
Implement seizure precautions.
RATIONALE: This patient could have encephalitis due to the hx of HIV and f ever. Seizure activity is
common.
#13: Findings: T5 SCI 6 months ago, f lushed f ace, prof use sweating, reports blurred vision, BP 145/95,
HR 68, O2 95%. Which of the f ollowing actions should the nurse take?
Palpate the patient’s bladder.
RATIONALE: Catheterize the patient with autonomic dysref lexia to decrease the pressure. This is an
emergency. Immediately elevated the HOB.
#14: The nurse working in the ED is caring f or a client admitted with a suspected spinal cord injury. It
would require f ollow up by the nurse if the PHCP prescribed which of the f ollowing?
Mannitol.
RATIONALE: Pg. 2291. Mannitol is used to treat ICP. Dextran, Atropine sulf ate, and Dopamine are
used to treat SCI.
#15: The nurse has taught a client who has myasthenia gravis about taking their prescribed
medications on time and 45-60 mins prior to meals. The client asks why timing is so important. Which
of the f ollowing is an appropriate response by the nurse?
This allows the medication to have maximum ef f ect, so it is easier f or you to chew and swallow.
RATIONALE: Pg. 2344. Drug Alert! Eat 45-60 mins prior to avoid aspiration.
#16: The nurse is working in the ED is caring f or a client who has MG. The client presents with muscle
weakness, NVD, and pulse of 58. Which of the f ollowing medications should the nurse admin
immediately?
Atropine sulf ate.
RATIONALE: Pg. 2345. In cholinergic crisis, admin Atropine I mg IV.
#17: The nurse preceptor is observing a newly hired nurse care f or a client who has MG. Which of the
f ollowing actions by the newly hired nurse requires immediate intervention by the nurse preceptor?
Preparing to admin a prescribed PRN laxative.
RATIONALE: Pg. 2346. Perf orm tasks during peak medication times, monitor serum albumin levels,
and provide high calorie snacks.
#18: The nurse is teaching a client who has recently diagnosed with trigeminal neuralgia. Which of the
, f ollowing statements by the client would indicate need f or f urther teaching?
I will tape my af f ected eye closed at bedtime.
RATIONALE: Pg. 2354. Seizure medication is f irst choice drug, f acial twitching or spasms may occur,
pain is usually provoked by minimal stimulation of a trigger zone (such as denture procedures.) Taping
of the eye is not necessary f or this patient.
#19: The nurse is provided teaching to a client who was just diagnosed with Bell’s palsy. Which of the
f ollowing client statements requires f ollow up by the nurse?
I will need to take carbamazepine to control my symptoms.
RATIONALE: Pg. 2255. This medication is used to treat TN. Patients will take steroids, use heat to
control pain, and may experience ringing of the ears.
#20: The nurse is caring f or the f ollowing assigned clients. It would be appropriate f or the nurse to
recommend a ref erral f or evaluation f or palliative care f or the client who
Has had ALS f or the past 3 years and was recently admitted with pain, f atigue, and d if f iculty
breathing.
RATIONALE: Pg. 2268. ALS is a chronic neurological disease that causes progressive muscle
weakness and wasting, leading to paralysis of respiratory muscles.
#21: The nurse is discussing advanced directives with a client who has ALS. The client tells the nurse “I
don’t want to be put on a breathing machine.” Which of the f ollowing is an appropriate response by the
nurse?
What would you like to be done if you start to have dif f iculty breathing?
RATIONA LE: Involve the client in their care, ask what they’d like to happen.
#22: The nurse has attended a CE conf erence on GB. Which of the f ollowing statements by the nurse
indicates a correct understanding of the conf erence?
The immune system reacts by destroying the myelin sheath.
RATIONALE: Pg. 2329. Primarily the axons are af f ected. In other f orms, demyelination typically begin in
the legs and spread to the arms and upper body.
#23: The nurse is assessing a client who has GB. The nurse notes diminished lung sounds, respirations
of 8 and shallow, and a pulse ox of 88%. Which of the f ollowing actions should the nurse take?
Prepare the client f or intubation.
RATIONALE: PG. 2334. The priority nursing intervention of airway management is to promote airway
latency and adequate gas exchange.
#24: The nurse is using the rule of 9s to calculate the extent of a clients burn injury. The client has
burns to the posterior area of the torso, arms, and legs. The nurse should document that the percent of
the body surf ace burned is:
45% 18 + 4.5 + 4.5 + 9 + 9 = 45
RATIONALE: Pg. 1302.
Rule of 9s f or estimating burn percentage.
Head A&P: 4.5%, 4.5%
Arms A&P: 4.5%, 4.5%
Torso A&P: 18%, 18%
Genitals: 1%
Legs A&P: 9%, 9%
and Answers Updated Top Rated
#1: The nurse is working in the emergency department (ED) is admitting a client who has sustained a
traumatic brain injury (TBI) f ollowing a motor vehicle crash. It is priority f or the nurse to notif y the
primary healthcare provider (PHCP) in the client:
Takes prescribed warf arin daily.
RATIONALE: Pg. 2400. Hemorrhage may occur as part of the primary injury and begin at the moment
of impact. Warf arin is a blood thinner and the patient may bleed out if they have a hematoma (a
collection of blood)
#2: The charge nurse is observing a newly hired nurse care f or a client who sustained a closed head
injury, is receiving mechanical ventilation, and is at risk f or developing ICP. Which of the f ollowing
actions, if perf ormed by the newly hired nurse, requires intervention by the charge nurse?
Raising the f oot of the client’s bed.
RATIONALE: Pg. 2413. Maintain the head midline, neutral position to prevent increased ICP.
#3: The newly hired nurse is caring f or a client who was admitted 12 hours ago with a TBI and is at risk
f or developing ICP. It requires intervention by the nurse preceptor if the newly hired nurse is observed
Clustering client care activities
RATIONALE: pg. 2387. When multiple activities are clustered in a row, the ef f ect on ICP can be
dramatic elevation.
#4: The nurse is assessing clients f or the risk of sustaining TBI. Which of the f ollowing clients should
the nurse identif y as being at greatest risk?
20 year old college student who participates on the f ootball team.
RATIONALE: Pg. 2397. A f orce produce by a blow direct to the head can contribute to a brain injury.
#5: The nurse is caring f or assigned clients. Which of the f ollowing assessment f indings requires the
nurse to notif y the PHCP?
The development of asymmetric pupils with no reaction to light in the client who has a TBI.
RATIONALE: Pg. 2386. Pupillary changes; dilated and non reactive pupils “blown” or constrictive, non
reactive pupils.
#6: The nurse is caring f or a client who had a TBI with skull f racture. The nurse noted that the client has
developed rhinorrhea (nasal drip) that is positive f or glucose. Which of the f ollowing actions should the
nurse take next?
Perf orm a halo sign test.
RATIONALE: Pg. 2410. CSF leaking, lab test will be analyzed f or glucose and electrolyte content. Place
on a white absorbent paper or linen.
#7: The nurse is providing discharge instructions to the partner of a client who sustained a mild head
injury as a result of a MVA. Which of the f ollowing statements, if made by the partners would indicated
the need f or additional teaching?
I will bring my partner to the ED if they immediately starting vomiting.
RATIONALE: Pg. 2405. Symptoms usually resolve within 72 hrs. NV expected.
#8: The nurse is caring f or the f ollowing assigned clients. Which client should the nurse see f irst?
, The client who has a brain injury and a BP change f rom 110/58 to 134/40 mm Hg.
RATIONALE: Pg. 2386. Cushing Triad. Severe HTN, widened pulse pressure, bradycardia.
#9: The nurse is caring f or a client who is 24 hours post op f ollowing a craniotomy. The client is
reporting a headache that is rated as an 8 on a scale of 0-10 pain scale. Which of the f ollowing actions
should the nurse take?
, Perf orm a neurological test.
RATIONALE: Pg. 2430. Symptoms of increased ICP included servers headache, deteriorating LOC,
restlessness, and irritability.
#10: The nurse is caring f or a client who has encephalitis. It is priority f or the nurse to f ollow up if the
client
Has a change in BP f rom 120/78 to 130/60 mm Hg.
RATIONALE: Pg. 2256. Changes in VS that require immediate notif ication to the HCP are a widened
pulse pressure, new bradycardia, and irregular respiratory ef f ort.
#11: The nurse is caring f or a client who has been admitted with suspected bacterial meningitis. Which
of the f ollowing actions should the nurse take f irst?
Prepare the client f or a lumbar puncture.
RATIONALE: Pg. 2251. Most signif icant lab test to determine BM is testing of CSF with a lumbar
puncture. A broad spectrum antibiotic is given bef ore the lumbar puncture.
#12: The nurse is caring f or the client who has conf usion, f ever, headache, blurred vision, NV, and a
history of HIV. Which of the f ollowing actions should the nurse take f irst?
Implement seizure precautions.
RATIONALE: This patient could have encephalitis due to the hx of HIV and f ever. Seizure activity is
common.
#13: Findings: T5 SCI 6 months ago, f lushed f ace, prof use sweating, reports blurred vision, BP 145/95,
HR 68, O2 95%. Which of the f ollowing actions should the nurse take?
Palpate the patient’s bladder.
RATIONALE: Catheterize the patient with autonomic dysref lexia to decrease the pressure. This is an
emergency. Immediately elevated the HOB.
#14: The nurse working in the ED is caring f or a client admitted with a suspected spinal cord injury. It
would require f ollow up by the nurse if the PHCP prescribed which of the f ollowing?
Mannitol.
RATIONALE: Pg. 2291. Mannitol is used to treat ICP. Dextran, Atropine sulf ate, and Dopamine are
used to treat SCI.
#15: The nurse has taught a client who has myasthenia gravis about taking their prescribed
medications on time and 45-60 mins prior to meals. The client asks why timing is so important. Which
of the f ollowing is an appropriate response by the nurse?
This allows the medication to have maximum ef f ect, so it is easier f or you to chew and swallow.
RATIONALE: Pg. 2344. Drug Alert! Eat 45-60 mins prior to avoid aspiration.
#16: The nurse is working in the ED is caring f or a client who has MG. The client presents with muscle
weakness, NVD, and pulse of 58. Which of the f ollowing medications should the nurse admin
immediately?
Atropine sulf ate.
RATIONALE: Pg. 2345. In cholinergic crisis, admin Atropine I mg IV.
#17: The nurse preceptor is observing a newly hired nurse care f or a client who has MG. Which of the
f ollowing actions by the newly hired nurse requires immediate intervention by the nurse preceptor?
Preparing to admin a prescribed PRN laxative.
RATIONALE: Pg. 2346. Perf orm tasks during peak medication times, monitor serum albumin levels,
and provide high calorie snacks.
#18: The nurse is teaching a client who has recently diagnosed with trigeminal neuralgia. Which of the
, f ollowing statements by the client would indicate need f or f urther teaching?
I will tape my af f ected eye closed at bedtime.
RATIONALE: Pg. 2354. Seizure medication is f irst choice drug, f acial twitching or spasms may occur,
pain is usually provoked by minimal stimulation of a trigger zone (such as denture procedures.) Taping
of the eye is not necessary f or this patient.
#19: The nurse is provided teaching to a client who was just diagnosed with Bell’s palsy. Which of the
f ollowing client statements requires f ollow up by the nurse?
I will need to take carbamazepine to control my symptoms.
RATIONALE: Pg. 2255. This medication is used to treat TN. Patients will take steroids, use heat to
control pain, and may experience ringing of the ears.
#20: The nurse is caring f or the f ollowing assigned clients. It would be appropriate f or the nurse to
recommend a ref erral f or evaluation f or palliative care f or the client who
Has had ALS f or the past 3 years and was recently admitted with pain, f atigue, and d if f iculty
breathing.
RATIONALE: Pg. 2268. ALS is a chronic neurological disease that causes progressive muscle
weakness and wasting, leading to paralysis of respiratory muscles.
#21: The nurse is discussing advanced directives with a client who has ALS. The client tells the nurse “I
don’t want to be put on a breathing machine.” Which of the f ollowing is an appropriate response by the
nurse?
What would you like to be done if you start to have dif f iculty breathing?
RATIONA LE: Involve the client in their care, ask what they’d like to happen.
#22: The nurse has attended a CE conf erence on GB. Which of the f ollowing statements by the nurse
indicates a correct understanding of the conf erence?
The immune system reacts by destroying the myelin sheath.
RATIONALE: Pg. 2329. Primarily the axons are af f ected. In other f orms, demyelination typically begin in
the legs and spread to the arms and upper body.
#23: The nurse is assessing a client who has GB. The nurse notes diminished lung sounds, respirations
of 8 and shallow, and a pulse ox of 88%. Which of the f ollowing actions should the nurse take?
Prepare the client f or intubation.
RATIONALE: PG. 2334. The priority nursing intervention of airway management is to promote airway
latency and adequate gas exchange.
#24: The nurse is using the rule of 9s to calculate the extent of a clients burn injury. The client has
burns to the posterior area of the torso, arms, and legs. The nurse should document that the percent of
the body surf ace burned is:
45% 18 + 4.5 + 4.5 + 9 + 9 = 45
RATIONALE: Pg. 1302.
Rule of 9s f or estimating burn percentage.
Head A&P: 4.5%, 4.5%
Arms A&P: 4.5%, 4.5%
Torso A&P: 18%, 18%
Genitals: 1%
Legs A&P: 9%, 9%
