NUR 242 MEDICAL-SURGICAL NURSING EXAM 1 2026/2027 |
Questions and Verified Answers | 100% Correct Grade A |
Galen College | Pass Guaranteed
Part I: Foundations of Med-Surg Nursing (Safety, Infection Control,
Oxygenation)
Q1: A 78-year-old patient admitted for hip replacement is ambulating in the hallway. The
nurse notes he is unsteady, uses furniture for support, and has a history of falls at
home. Which fall risk assessment tool is most appropriate for this medical-surgical
patient?
A. Mini-Mental State Examination (MMSE) for cognitive screening
B. Morse Fall Scale or Hendrich II Fall Risk Model [CORRECT]
C. Braden Scale for pressure injury risk
D. Glasgow Coma Scale for neurological assessment
Correct Answer: B
Rationale: The Morse Fall Scale and Hendrich II Fall Risk Model are validated tools
specifically designed for adult medical-surgical patients to assess fall risk. The Morse
Scale evaluates history of falling, secondary diagnosis, ambulatory aid, IV therapy, gait,
and mental status. The Hendrich II is particularly sensitive for acute care settings. The
Braden Scale assesses pressure injury risk, not falls.
,Q2: A nurse is preparing to administer medications to a patient. Which action
demonstrates the "right medication" component of medication safety?
A. Checking the patient's wristband against the chart
B. Comparing the medication label to the medication administration record three times
[CORRECT]
C. Asking the patient to state their name and date of birth
D. Documenting the medication after administration
Correct Answer: B
Rationale: The "right medication" requires comparing the medication label to the MAR
three times: when removing from storage, when preparing, and at the bedside before
administration. Checking wristbands addresses "right patient," and post-administration
documentation is "right documentation." The five rights are patient, medication, dose,
route, and time.
Q3: A patient has been bedbound for 5 days and has limited mobility due to a fractured
femur. Which assessment tool should the nurse use to evaluate this patient's risk for
pressure injury development?
A. Morse Fall Scale for fall risk
B. Braden Scale for pressure injury risk [CORRECT]
C. Aldrete Score for post-anesthesia recovery
D. APACHE II for illness severity
,Correct Answer: B
Rationale: The Braden Scale is the most widely used tool for predicting pressure injury
risk. It assesses six subscales: sensory perception, moisture, activity, mobility, nutrition,
and friction/shear. Scores ≤18 indicate at-risk status. This bedbound patient with limited
mobility is at high risk and requires preventive interventions (repositioning, pressure
redistribution surfaces).
Q4: A nurse is caring for a patient who is agitated and attempting to remove their IV line.
The physician orders wrist restraints. Which nursing action is required?
A. Apply restraints immediately and notify physician within 24 hours
B. Ensure physician order, use least restrictive alternative, monitor every 2 hours, and
re-evaluate need [CORRECT]
C. Apply restraints only when family is present to assist
D. Use restraints continuously without reassessment until discharge
Correct Answer: B
Rationale: Restraint use requires: valid physician order (time-limited, typically 24 hours),
documentation that less restrictive alternatives were attempted or considered,
application per policy, monitoring every 1-2 hours (neurovascular checks, basic needs),
and ongoing reassessment of continued necessity. Restraints are last resort for patient
safety, not convenience.
Q5: A nurse enters a patient's room to perform wound dressing changes. Which hand
hygiene method is appropriate?
, A. Alcohol-based hand rub for visible soiling on hands
B. Soap and water washing for visible soiling or after restroom use [CORRECT]
C. No hand hygiene needed if gloves will be worn
D. Alcohol-based rub only after removing gloves
Correct Answer: B
Rationale: The CDC guidelines state: use alcohol-based hand rub for routine
decontamination when hands are not visibly soiled; use soap and water when hands are
visibly dirty/contaminated, after using the restroom, or when caring for patients with C.
difficile or norovirus (alcohol is ineffective against spores). Hand hygiene is always
required before and after glove use.
Q6: A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA)
wound infection. Which transmission-based precautions are required?
A. Droplet precautions with mask within 3 feet
B. Contact precautions with gown and gloves [CORRECT]
C. Airborne precautions with N95 respirator
D. Standard precautions only
Correct Answer: B
Rationale: MRSA requires contact precautions: gown and gloves for room entry,
dedicated equipment or thorough disinfection between uses, and private room or
cohorting. Contact precautions are used for organisms transmitted by direct patient
Questions and Verified Answers | 100% Correct Grade A |
Galen College | Pass Guaranteed
Part I: Foundations of Med-Surg Nursing (Safety, Infection Control,
Oxygenation)
Q1: A 78-year-old patient admitted for hip replacement is ambulating in the hallway. The
nurse notes he is unsteady, uses furniture for support, and has a history of falls at
home. Which fall risk assessment tool is most appropriate for this medical-surgical
patient?
A. Mini-Mental State Examination (MMSE) for cognitive screening
B. Morse Fall Scale or Hendrich II Fall Risk Model [CORRECT]
C. Braden Scale for pressure injury risk
D. Glasgow Coma Scale for neurological assessment
Correct Answer: B
Rationale: The Morse Fall Scale and Hendrich II Fall Risk Model are validated tools
specifically designed for adult medical-surgical patients to assess fall risk. The Morse
Scale evaluates history of falling, secondary diagnosis, ambulatory aid, IV therapy, gait,
and mental status. The Hendrich II is particularly sensitive for acute care settings. The
Braden Scale assesses pressure injury risk, not falls.
,Q2: A nurse is preparing to administer medications to a patient. Which action
demonstrates the "right medication" component of medication safety?
A. Checking the patient's wristband against the chart
B. Comparing the medication label to the medication administration record three times
[CORRECT]
C. Asking the patient to state their name and date of birth
D. Documenting the medication after administration
Correct Answer: B
Rationale: The "right medication" requires comparing the medication label to the MAR
three times: when removing from storage, when preparing, and at the bedside before
administration. Checking wristbands addresses "right patient," and post-administration
documentation is "right documentation." The five rights are patient, medication, dose,
route, and time.
Q3: A patient has been bedbound for 5 days and has limited mobility due to a fractured
femur. Which assessment tool should the nurse use to evaluate this patient's risk for
pressure injury development?
A. Morse Fall Scale for fall risk
B. Braden Scale for pressure injury risk [CORRECT]
C. Aldrete Score for post-anesthesia recovery
D. APACHE II for illness severity
,Correct Answer: B
Rationale: The Braden Scale is the most widely used tool for predicting pressure injury
risk. It assesses six subscales: sensory perception, moisture, activity, mobility, nutrition,
and friction/shear. Scores ≤18 indicate at-risk status. This bedbound patient with limited
mobility is at high risk and requires preventive interventions (repositioning, pressure
redistribution surfaces).
Q4: A nurse is caring for a patient who is agitated and attempting to remove their IV line.
The physician orders wrist restraints. Which nursing action is required?
A. Apply restraints immediately and notify physician within 24 hours
B. Ensure physician order, use least restrictive alternative, monitor every 2 hours, and
re-evaluate need [CORRECT]
C. Apply restraints only when family is present to assist
D. Use restraints continuously without reassessment until discharge
Correct Answer: B
Rationale: Restraint use requires: valid physician order (time-limited, typically 24 hours),
documentation that less restrictive alternatives were attempted or considered,
application per policy, monitoring every 1-2 hours (neurovascular checks, basic needs),
and ongoing reassessment of continued necessity. Restraints are last resort for patient
safety, not convenience.
Q5: A nurse enters a patient's room to perform wound dressing changes. Which hand
hygiene method is appropriate?
, A. Alcohol-based hand rub for visible soiling on hands
B. Soap and water washing for visible soiling or after restroom use [CORRECT]
C. No hand hygiene needed if gloves will be worn
D. Alcohol-based rub only after removing gloves
Correct Answer: B
Rationale: The CDC guidelines state: use alcohol-based hand rub for routine
decontamination when hands are not visibly soiled; use soap and water when hands are
visibly dirty/contaminated, after using the restroom, or when caring for patients with C.
difficile or norovirus (alcohol is ineffective against spores). Hand hygiene is always
required before and after glove use.
Q6: A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA)
wound infection. Which transmission-based precautions are required?
A. Droplet precautions with mask within 3 feet
B. Contact precautions with gown and gloves [CORRECT]
C. Airborne precautions with N95 respirator
D. Standard precautions only
Correct Answer: B
Rationale: MRSA requires contact precautions: gown and gloves for room entry,
dedicated equipment or thorough disinfection between uses, and private room or
cohorting. Contact precautions are used for organisms transmitted by direct patient
