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NSG233 EXAM 3 /NSG 233 MED SURG III EXAM 3
NEWEST 2025/2026 COMPLETE 100 QUESTIONS
AND CORRECT ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+||BRAND NEW
VERSION!!
A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
- Ensure that informed consent is on the chart.
- Document these findings in the clients record.
- Give the prescribed preprocedure sedation.
- Notify the provider of the findings immediately. - ANSWER-D
Rationale: This client is exhibiting signs of increased intracranial
pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be cancelled.
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After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best?
- Assess the clients magnesium level.
- Assess the clients sodium level.
- Increase the rate of the IV infusion.
- Provide oral care every hour. - ANSWER-B
Rationale: This client has manifestations of hypernatremia, which is a
possible complication after a craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.
A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?
- Increased pressure from the abscess can cause seizures.
- Preventing febrile seizures with an abscess is important.
- Seizures always occur in clients with brain abscesses.
- This drug is used to sedate the client with an abscess. - ANSWER-A
Rationale: Brain abscesses can lead to seizures as a complication. The
nurse should explain this to the spouse. Phenytoin is not used to 2 / 4
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prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.
A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke?
- A 27-year-old heavy cocaine user
- A 30-year-old who drinks a beer a day
- A 40-year-old who uses seasonal antihistamines
- A 65-year-old who is active and on no medications - ANSWER-A
Rationale: Heavy drug use, particularly cocaine, is a risk factor for
stroke. Heavy alcohol is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.
A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met?
- Chooses preferred items from the menu
- Eats 75% to 100% of all meals and snacks
- Has clear lung sounds on auscultation
- Gains 2 pounds after 1 week - ANSWER-C 3 / 4
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Rationale: Impaired swallowing can lead to aspiration, so the priority
goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.
A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client?
- Impending brain herniation
- Poor prognosis and cognitive function
- Probable complete recovery
- Unable to tell from this information - ANSWER-B
Rationale: The cerebral perfusion pressure (CPP) is the intracranial
pressure subtracted from the mean arterial pressure: in this case, 60-
20=40. For optimal outcomes, CPP should be at least 70 mmHg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.
A client has a traumatic brain injury. The nurse assesses the following:
pulse change from 82 to 60 beats/min, pulse pressure increase from 26
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