Test Bank Medical Surgical Nursing over 500 questions and answers
Topic 1: Perioperative Nursing
1. A patient is scheduled for surgery tomorrow morning. The nurse notes that the patient took aspirin
this morning. What is the priority nursing action?
a. Document the finding and notify the surgeon
b. Tell the patient to stop taking aspirin immediately
c. Administer vitamin K to reverse the aspirin effect
d. Continue preoperative teaching as planned
Answer: a. Document the finding and notify the surgeon
Rationale: Aspirin inhibits platelet aggregation and increases bleeding risk. The surgeon should be
notified as surgery may need to be postponed or special precautions taken.
2. The nurse is providing preoperative teaching to a patient scheduled for abdominal surgery. Which
statement by the patient indicates a need for further teaching?
a. "I will need to do deep breathing and coughing exercises after surgery."
b. "I will be able to drink clear liquids up until the time of surgery."
c. "I should let my nurse know if I have any pain after surgery."
d. "I may have a tube in my nose that goes to my stomach after surgery."
Answer: b. "I will be able to drink clear liquids up until the time of surgery."
Rationale: Patients are typically NPO (nothing by mouth) for 6-8 hours before surgery to reduce
aspiration risk. Clear liquids are not allowed immediately before surgery.
3. The nurse is reviewing a patient's preoperative laboratory results. Which finding is most
concerning?
a. Hemoglobin 12 g/dL
b. Potassium 3.5 mEq/L
c. White blood cell count 15,000/mm³
d. Platelets 200,000/mm³
Answer: c. White blood cell count 15,000/mm³
Rationale: Elevated WBC may indicate infection, which could delay surgery. Normal WBC is 4,500-
11,000/mm³. Hemoglobin 12 is slightly low but not emergent; potassium 3.5 is at low normal.
4. The nurse is preparing a patient for surgery. Which medication should be withheld preoperatively?
a. Metoprolol
b. Insulin
c. Warfarin
d. Acetaminophen
,Answer: c. Warfarin
Rationale: Anticoagulants like warfarin increase bleeding risk and are often withheld preoperatively.
Beta-blockers and insulin are usually continued; acetaminophen is safe.
5. During the immediate postoperative period, the nurse assesses a patient who had general
anesthesia. Which finding requires immediate intervention?
a. Oxygen saturation of 92%
b. Respiratory rate of 10 breaths per minute
c. Heart rate of 88 beats per minute
d. Temperature of 97.8°F (36.6°C)
Answer: b. Respiratory rate of 10 breaths per minute
Rationale: Respiratory depression (RR <12) may indicate residual anesthetic effects or opioid overdose
and requires immediate intervention.
6. The nurse is caring for a patient on the first postoperative day after abdominal surgery. Which
finding is most indicative of a potential complication?
a. Pain rated 5 out of 10
b. Temperature of 100.8°F (38.2°C)
c. Wound edges that are approximated
d. Small amount of serosanguinous drainage
Answer: b. Temperature of 100.8°F (38.2°C)
Rationale: Fever in the first 24-48 hours post-op may indicate atelectasis but can also be a sign of
infection. Mild fever requires monitoring; higher fever or later onset is more concerning.
7. The nurse is teaching a patient about deep breathing and coughing exercises after surgery. What is
the primary purpose of these exercises?
a. To prevent atelectasis and pneumonia
b. To improve oxygenation
c. To decrease pain
d. To promote wound healing
Answer: a. To prevent atelectasis and pneumonia
Rationale: Deep breathing and coughing help expand alveoli and mobilize secretions, preventing
atelectasis and postoperative pneumonia.
8. A patient who had surgery 8 hours ago has not voided. The nurse palpates a distended bladder.
What is the priority nursing action?
a. Insert a Foley catheter
b. Encourage the patient to drink more fluids
c. Assess for bladder distention and encourage voiding
d. Administer a diuretic
,Answer: c. Assess for bladder distention and encourage voiding
Rationale: Urinary retention is common postoperatively. Non-invasive measures (privacy, running water,
positioning) should be attempted before catheterization.
9. The nurse is assessing a patient's surgical incision on the third postoperative day. Which finding is
most concerning?
a. Slight erythema at the wound edges
b. Serosanguinous drainage on the dressing
c. Wound edges that are separating
d. Edema around the incision site
Answer: c. Wound edges that are separating
Rationale: Wound dehiscence (separation of wound edges) is a serious complication requiring immediate
intervention.
10. A patient reports a sudden "popping" sensation at the surgical site followed by drainage of large
amounts of fluid. What is the priority nursing action?
a. Apply a dry sterile dressing
b. Place the patient in Trendelenburg position
c. Cover the wound with a sterile saline-moistened dressing and notify the surgeon
d. Measure the amount of drainage
Answer: c. Cover the wound with a sterile saline-moistened dressing and notify the surgeon
Rationale: This describes wound dehiscence or evisceration. The wound should be covered with sterile
saline-moistened gauze, and the surgeon should be notified immediately.
Topic 2: Fluid and Electrolyte Balance
11. The nurse is assessing a patient with dehydration. Which finding is expected?
a. Bounding pulse
b. Jugular vein distention
c. Poor skin turgor
d. Peripheral edema
Answer: c. Poor skin turgor
Rationale: Dehydration causes decreased skin turgor (tenting), dry mucous membranes, tachycardia, and
hypotension.
12. A patient has a serum sodium level of 125 mEq/L. Which assessment finding is most concerning?
a. Dry mucous membranes
b. Muscle cramps
c. Altered mental status
d. Hypotension
, Answer: c. Altered mental status
Rationale: Hyponatremia (Na <135) can cause cerebral edema, leading to confusion, seizures, and coma.
Altered mental status is a priority.
13. The nurse is caring for a patient with hyperkalemia. Which intervention is most important?
a. Administer furosemide as ordered
b. Monitor cardiac rhythm
c. Encourage potassium-rich foods
d. Restrict fluid intake
Answer: b. Monitor cardiac rhythm
Rationale: Hyperkalemia (K >5.0) causes cardiac conduction abnormalities, including peaked T waves,
widened QRS, and potentially cardiac arrest. Cardiac monitoring is priority.
14. A patient with hypokalemia is receiving IV potassium chloride. Which action is essential for the
nurse to take?
a. Administer as a rapid IV push
b. Ensure the IV site is patent and use an infusion pump
c. Mix with dextrose solution
d. Administer undiluted
Answer: b. Ensure the IV site is patent and use an infusion pump
Rationale: IV potassium is never given as a bolus or undiluted. It must be diluted, administered slowly via
infusion pump, and monitored for infiltration (which can cause tissue necrosis).
15. The nurse is assessing a patient with fluid volume overload. Which finding is expected?
a. Decreased blood pressure
b. Flat neck veins
c. Bounding pulses
d. Increased hematocrit
Answer: c. Bounding pulses
Rationale: Fluid volume overload causes bounding pulses, elevated blood pressure, distended neck
veins, and crackles in the lungs.
16. A patient has a serum calcium level of 7.5 mg/dL. Which assessment finding is associated with this
condition?
a. Positive Chvostek's sign
b. Bone pain
c. Constipation
d. Hypertension
Topic 1: Perioperative Nursing
1. A patient is scheduled for surgery tomorrow morning. The nurse notes that the patient took aspirin
this morning. What is the priority nursing action?
a. Document the finding and notify the surgeon
b. Tell the patient to stop taking aspirin immediately
c. Administer vitamin K to reverse the aspirin effect
d. Continue preoperative teaching as planned
Answer: a. Document the finding and notify the surgeon
Rationale: Aspirin inhibits platelet aggregation and increases bleeding risk. The surgeon should be
notified as surgery may need to be postponed or special precautions taken.
2. The nurse is providing preoperative teaching to a patient scheduled for abdominal surgery. Which
statement by the patient indicates a need for further teaching?
a. "I will need to do deep breathing and coughing exercises after surgery."
b. "I will be able to drink clear liquids up until the time of surgery."
c. "I should let my nurse know if I have any pain after surgery."
d. "I may have a tube in my nose that goes to my stomach after surgery."
Answer: b. "I will be able to drink clear liquids up until the time of surgery."
Rationale: Patients are typically NPO (nothing by mouth) for 6-8 hours before surgery to reduce
aspiration risk. Clear liquids are not allowed immediately before surgery.
3. The nurse is reviewing a patient's preoperative laboratory results. Which finding is most
concerning?
a. Hemoglobin 12 g/dL
b. Potassium 3.5 mEq/L
c. White blood cell count 15,000/mm³
d. Platelets 200,000/mm³
Answer: c. White blood cell count 15,000/mm³
Rationale: Elevated WBC may indicate infection, which could delay surgery. Normal WBC is 4,500-
11,000/mm³. Hemoglobin 12 is slightly low but not emergent; potassium 3.5 is at low normal.
4. The nurse is preparing a patient for surgery. Which medication should be withheld preoperatively?
a. Metoprolol
b. Insulin
c. Warfarin
d. Acetaminophen
,Answer: c. Warfarin
Rationale: Anticoagulants like warfarin increase bleeding risk and are often withheld preoperatively.
Beta-blockers and insulin are usually continued; acetaminophen is safe.
5. During the immediate postoperative period, the nurse assesses a patient who had general
anesthesia. Which finding requires immediate intervention?
a. Oxygen saturation of 92%
b. Respiratory rate of 10 breaths per minute
c. Heart rate of 88 beats per minute
d. Temperature of 97.8°F (36.6°C)
Answer: b. Respiratory rate of 10 breaths per minute
Rationale: Respiratory depression (RR <12) may indicate residual anesthetic effects or opioid overdose
and requires immediate intervention.
6. The nurse is caring for a patient on the first postoperative day after abdominal surgery. Which
finding is most indicative of a potential complication?
a. Pain rated 5 out of 10
b. Temperature of 100.8°F (38.2°C)
c. Wound edges that are approximated
d. Small amount of serosanguinous drainage
Answer: b. Temperature of 100.8°F (38.2°C)
Rationale: Fever in the first 24-48 hours post-op may indicate atelectasis but can also be a sign of
infection. Mild fever requires monitoring; higher fever or later onset is more concerning.
7. The nurse is teaching a patient about deep breathing and coughing exercises after surgery. What is
the primary purpose of these exercises?
a. To prevent atelectasis and pneumonia
b. To improve oxygenation
c. To decrease pain
d. To promote wound healing
Answer: a. To prevent atelectasis and pneumonia
Rationale: Deep breathing and coughing help expand alveoli and mobilize secretions, preventing
atelectasis and postoperative pneumonia.
8. A patient who had surgery 8 hours ago has not voided. The nurse palpates a distended bladder.
What is the priority nursing action?
a. Insert a Foley catheter
b. Encourage the patient to drink more fluids
c. Assess for bladder distention and encourage voiding
d. Administer a diuretic
,Answer: c. Assess for bladder distention and encourage voiding
Rationale: Urinary retention is common postoperatively. Non-invasive measures (privacy, running water,
positioning) should be attempted before catheterization.
9. The nurse is assessing a patient's surgical incision on the third postoperative day. Which finding is
most concerning?
a. Slight erythema at the wound edges
b. Serosanguinous drainage on the dressing
c. Wound edges that are separating
d. Edema around the incision site
Answer: c. Wound edges that are separating
Rationale: Wound dehiscence (separation of wound edges) is a serious complication requiring immediate
intervention.
10. A patient reports a sudden "popping" sensation at the surgical site followed by drainage of large
amounts of fluid. What is the priority nursing action?
a. Apply a dry sterile dressing
b. Place the patient in Trendelenburg position
c. Cover the wound with a sterile saline-moistened dressing and notify the surgeon
d. Measure the amount of drainage
Answer: c. Cover the wound with a sterile saline-moistened dressing and notify the surgeon
Rationale: This describes wound dehiscence or evisceration. The wound should be covered with sterile
saline-moistened gauze, and the surgeon should be notified immediately.
Topic 2: Fluid and Electrolyte Balance
11. The nurse is assessing a patient with dehydration. Which finding is expected?
a. Bounding pulse
b. Jugular vein distention
c. Poor skin turgor
d. Peripheral edema
Answer: c. Poor skin turgor
Rationale: Dehydration causes decreased skin turgor (tenting), dry mucous membranes, tachycardia, and
hypotension.
12. A patient has a serum sodium level of 125 mEq/L. Which assessment finding is most concerning?
a. Dry mucous membranes
b. Muscle cramps
c. Altered mental status
d. Hypotension
, Answer: c. Altered mental status
Rationale: Hyponatremia (Na <135) can cause cerebral edema, leading to confusion, seizures, and coma.
Altered mental status is a priority.
13. The nurse is caring for a patient with hyperkalemia. Which intervention is most important?
a. Administer furosemide as ordered
b. Monitor cardiac rhythm
c. Encourage potassium-rich foods
d. Restrict fluid intake
Answer: b. Monitor cardiac rhythm
Rationale: Hyperkalemia (K >5.0) causes cardiac conduction abnormalities, including peaked T waves,
widened QRS, and potentially cardiac arrest. Cardiac monitoring is priority.
14. A patient with hypokalemia is receiving IV potassium chloride. Which action is essential for the
nurse to take?
a. Administer as a rapid IV push
b. Ensure the IV site is patent and use an infusion pump
c. Mix with dextrose solution
d. Administer undiluted
Answer: b. Ensure the IV site is patent and use an infusion pump
Rationale: IV potassium is never given as a bolus or undiluted. It must be diluted, administered slowly via
infusion pump, and monitored for infiltration (which can cause tissue necrosis).
15. The nurse is assessing a patient with fluid volume overload. Which finding is expected?
a. Decreased blood pressure
b. Flat neck veins
c. Bounding pulses
d. Increased hematocrit
Answer: c. Bounding pulses
Rationale: Fluid volume overload causes bounding pulses, elevated blood pressure, distended neck
veins, and crackles in the lungs.
16. A patient has a serum calcium level of 7.5 mg/dL. Which assessment finding is associated with this
condition?
a. Positive Chvostek's sign
b. Bone pain
c. Constipation
d. Hypertension
