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NUR 265 Advanced Med-Surg Practice Exam
High-Level NCLEX Style Questions with Rationales
1. A nurse is caring for a client with increased intracranial
pressure (ICP). Which finding requires immediate
intervention?
A. Headache B. Restlessness C. Bradycardia and irregular respirations D. Photophobia Answer: C. Bradycardia and irregular respirations Rationale: Bradycardia with irregular respirations are late signs of ICP and indicate possible brain herniation.
2. A client with Guillain-Barré syndrome develops shortness
of breath. What is the nurse’s priority action?
A. Administer pain medication B. Assess respiratory function C. Encourage ambulation D. Limit fluid intake Answer: B. Assess respiratory function Rationale: Respiratory failure is the most life-threatening complication of Guillain-Barré syndrome.
3. Which assessment finding is an EARLY sign of shock?
A. Hypotension B. Organ failure C. Tachycardia D. Bradycardia Answer: C. Tachycardia Rationale: Tachycardia is an early compensatory response to shock.
4. A nurse suspects autonomic dysreflexia in a client with a
spinal cord injury. What should the nurse do FIRST?
A. Lower the head of the bed B. Assess bowel sounds C. Sit the patient upright D. Administer oxygen Answer: C. Sit the patient upright Rationale: Sitting upright helps decrease severe hypertension associated with autonomic dysreflexia.
5. Which finding is expected in neurogenic shock?
A. Warm dry skin and bradycardia B. Cool clammy skin C. Severe hypertension D. Tachycardia Answer: A. Warm dry skin and bradycardia Rationale: Neurogenic shock causes loss of sympathetic tone leading to hypotension and bradycardia.
6. A client with meningitis is admitted to the unit. Which
intervention should the nurse implement FIRST?
A. Place the client in droplet precautions B. Encourage oral fluids C. Administer pain medication D. Perform passive ROM Answer: A. Place the client in droplet precautions Rationale: Bacterial meningitis requires immediate droplet precautions to prevent transmission.
7. Which assessment finding indicates a LATE sign of
increased ICP?
A. Restlessness B. Headache C. Decreased LOC D. Fixed dilated pupils Answer: D. Fixed dilated pupils Rationale: Fixed dilated pupils indicate severe neurological deterioration.
8. A burn client has singed nasal hairs and soot around the
mouth. What is the priority nursing intervention?
12. A nurse is caring for a client in septic shock. Which
intervention should occur FIRST?
A. Administer broad-spectrum antibiotics B. Restrict fluids C. Encourage ambulation D. Obtain a stool sample Answer: A. Administer broad-spectrum antibiotics Rationale: Early antibiotic therapy is critical in septic shock management.
13. Which finding is expected in a client experiencing
hypovolemic shock?
A. Bradycardia B. Warm flushed skin C. Cool clammy skin D. Bounding pulses Answer: C. Cool clammy skin Rationale: Peripheral vasoconstriction causes cool clammy skin in hypovolemic shock.
14. A client with Guillain-Barré syndrome reports tingling in
the feet. What should the nurse recognize?
A. Expected early manifestation B. Sign of recovery C. Medication reaction D. Late neurological decline Answer: A. Expected early manifestation Rationale: Ascending paresthesia is an early symptom of Guillain-Barré syndrome.
15. A client with meningitis becomes increasingly confused
and restless. What action should the nurse take?
A. Document as expected B. Increase environmental stimulation C. Perform neurological reassessment D. Encourage ambulation
Answer: C. Perform neurological reassessment Rationale: Changes in LOC may indicate worsening neurological status.
