NUR 242 MEDICAL-SURGICAL NURSING EXAM 1 REVIEW
2026/2027 | Complete Guide with Questions and Verified
Answers | 100% Correct | Pass Guaranteed - A+ Graded
Part I: Foundations of Med-Surg Nursing (Safety, Infection Control,
Oxygenation) – Questions 1–16
Q1: A 78-year-old patient admitted for hip replacement is assessed for fall risk. Which
finding would most increase the Morse Fall Scale score?
A. Patient uses a walker at home occasionally
B. Patient has a history of falls within the past 3 months [CORRECT]
C. Patient takes a daily multivitamin
D. Patient prefers to sleep with the bed in low position
Correct Answer: B
Rationale: The Morse Fall Scale assigns 25 points for history of falls (highest single
item), significantly increasing risk classification. Assistive device use scores 15 points;
medications aren't directly scored; bed position is an intervention, not a risk factor. Fall
history is the strongest predictor of future falls.
Q2: A nurse is preparing to administer medications to a patient with a known penicillin
allergy. Which "right" of medication administration is most critical to verify first?
A. Right route
B. Right documentation
C. Right medication [CORRECT]
D. Right time
Correct Answer: C
,Rationale: The right medication is foundational—giving the wrong drug (especially a
penicillin to an allergic patient) causes harm regardless of other rights. While all rights
matter, medication verification including allergy cross-checks comes first. Route,
documentation, and timing are secondary to giving the correct drug safely.
Q3: A patient with C. difficile infection needs to use the restroom. Which hand hygiene
approach is appropriate for the nurse after assisting?
A. Alcohol-based hand rub (ABHR) for 20 seconds
B. Soap and water for at least 30 seconds [CORRECT]
C. Either ABHR or soap and water are equally effective
D. No hand hygiene needed if gloves were worn
Correct Answer: B
Rationale: C. difficile forms spores resistant to alcohol. Soap and water with mechanical
friction physically removes spores; ABHR doesn't kill them. "Either" is incorrect for C. diff
specifically; gloves reduce but don't eliminate hand contamination requiring hygiene.
Q4: A patient with suspected tuberculosis is admitted. Which transmission-based
precautions are required?
A. Contact precautions with gown and gloves
B. Droplet precautions with surgical mask within 3 feet
C. Airborne precautions with N95 respirator and negative pressure room [CORRECT]
D. Standard precautions only with hand hygiene
Correct Answer: C
Rationale: TB is airborne—droplet nuclei <5 microns remain suspended, requiring N95
respirator (fit-tested) and negative pressure room (≥12 air exchanges/hour). Contact
precautions are for direct contact diseases; droplet for larger respiratory droplets;
standard precautions apply to all patients but aren't sufficient for TB.
,Q5: A patient shows early signs of hypoxia. Which manifestation would the nurse expect
to see first?
A. Bradycardia and cyanosis
B. Tachycardia and restlessness [CORRECT]
C. Bradypnea and lethargy
D. Hypotension and unresponsiveness
Correct Answer: B
Rationale: Early hypoxia triggers compensatory mechanisms: tachycardia (increased
cardiac output), tachypnea (increased respiratory rate), and restlessness/anxiety (CNS
response to hypoxemia). Bradycardia, cyanosis, bradypnea, and lethargy are late signs
of severe hypoxia; hypotension and unresponsiveness indicate decompensation.
Q6: A patient with COPD is prescribed oxygen therapy. Which delivery device allows the
most precise FiO2 control?
A. Nasal cannula at 4 L/min
B. Simple face mask at 8 L/min
C. Venturi mask with color-coded adapter [CORRECT]
D. Non-rebreather mask at 12 L/min
Correct Answer: C
Rationale: The Venturi mask mixes room air with oxygen using color-coded adapters,
delivering precise FiO2 (24-50%) regardless of breathing pattern. Nasal cannula and
simple mask vary with respiratory rate; non-rebreather delivers high FiO2 but less
precisely. COPD patients often need controlled, low FiO2 to avoid CO2 retention.
Q7: A nurse is opening a sterile package for a wound dressing change. Which action
maintains sterile technique?
A. Opening the package with the flaps away from the sterile field
B. Reaching over the sterile field to retrieve supplies
C. Touching the outer 1-inch border of the sterile drape to position it
D. Turning back to the sterile field after touching the patient's bed rail
, Correct Answer: A
Rationale: Flaps should open away from the sterile field to prevent contamination from
hands/package surfaces. Reaching over, touching the 1-inch border (considered
contaminated), and turning your back to the field all violate sterile principles. Sterile
team members must face the field at all times.
Q8: A patient has a Braden Scale score of 14. Which nursing intervention is most
appropriate?
A. Standard mattress with repositioning every 4 hours
B. Pressure-reducing mattress and repositioning every 2 hours [CORRECT]
C. No special interventions needed; score indicates low risk
D. Massage bony prominences every hour to increase circulation
Correct Answer: B
Rationale: Braden Scale: 15-18 = mild risk, 13-14 = moderate risk, 10-12 = high risk, ≤9 =
very high. Score 14 indicates moderate risk requiring pressure-reducing surfaces and
q2h repositioning. Standard mattress is insufficient; massage doesn't prevent pressure
injury and may damage tissue; the score clearly indicates risk requiring intervention.
Q9: A patient requires restraints for safety. Which nursing action follows best practice?
A. Apply four-point restraints immediately when the patient becomes agitated
B. Use the least restrictive method first, obtain physician order, and monitor every 2
hours [CORRECT]
C. Check the restrained extremities once per shift for circulation
D. Keep restraints applied continuously until discharge to prevent falls
Correct Answer: B
Rationale: Restraint guidelines: (1) Least restrictive alternatives first (verbal
de-escalation, sitters, environmental modifications), (2) Physician order required
(time-limited, typically 24 hours), (3) Frequent monitoring (q2h for adults: circulation,
2026/2027 | Complete Guide with Questions and Verified
Answers | 100% Correct | Pass Guaranteed - A+ Graded
Part I: Foundations of Med-Surg Nursing (Safety, Infection Control,
Oxygenation) – Questions 1–16
Q1: A 78-year-old patient admitted for hip replacement is assessed for fall risk. Which
finding would most increase the Morse Fall Scale score?
A. Patient uses a walker at home occasionally
B. Patient has a history of falls within the past 3 months [CORRECT]
C. Patient takes a daily multivitamin
D. Patient prefers to sleep with the bed in low position
Correct Answer: B
Rationale: The Morse Fall Scale assigns 25 points for history of falls (highest single
item), significantly increasing risk classification. Assistive device use scores 15 points;
medications aren't directly scored; bed position is an intervention, not a risk factor. Fall
history is the strongest predictor of future falls.
Q2: A nurse is preparing to administer medications to a patient with a known penicillin
allergy. Which "right" of medication administration is most critical to verify first?
A. Right route
B. Right documentation
C. Right medication [CORRECT]
D. Right time
Correct Answer: C
,Rationale: The right medication is foundational—giving the wrong drug (especially a
penicillin to an allergic patient) causes harm regardless of other rights. While all rights
matter, medication verification including allergy cross-checks comes first. Route,
documentation, and timing are secondary to giving the correct drug safely.
Q3: A patient with C. difficile infection needs to use the restroom. Which hand hygiene
approach is appropriate for the nurse after assisting?
A. Alcohol-based hand rub (ABHR) for 20 seconds
B. Soap and water for at least 30 seconds [CORRECT]
C. Either ABHR or soap and water are equally effective
D. No hand hygiene needed if gloves were worn
Correct Answer: B
Rationale: C. difficile forms spores resistant to alcohol. Soap and water with mechanical
friction physically removes spores; ABHR doesn't kill them. "Either" is incorrect for C. diff
specifically; gloves reduce but don't eliminate hand contamination requiring hygiene.
Q4: A patient with suspected tuberculosis is admitted. Which transmission-based
precautions are required?
A. Contact precautions with gown and gloves
B. Droplet precautions with surgical mask within 3 feet
C. Airborne precautions with N95 respirator and negative pressure room [CORRECT]
D. Standard precautions only with hand hygiene
Correct Answer: C
Rationale: TB is airborne—droplet nuclei <5 microns remain suspended, requiring N95
respirator (fit-tested) and negative pressure room (≥12 air exchanges/hour). Contact
precautions are for direct contact diseases; droplet for larger respiratory droplets;
standard precautions apply to all patients but aren't sufficient for TB.
,Q5: A patient shows early signs of hypoxia. Which manifestation would the nurse expect
to see first?
A. Bradycardia and cyanosis
B. Tachycardia and restlessness [CORRECT]
C. Bradypnea and lethargy
D. Hypotension and unresponsiveness
Correct Answer: B
Rationale: Early hypoxia triggers compensatory mechanisms: tachycardia (increased
cardiac output), tachypnea (increased respiratory rate), and restlessness/anxiety (CNS
response to hypoxemia). Bradycardia, cyanosis, bradypnea, and lethargy are late signs
of severe hypoxia; hypotension and unresponsiveness indicate decompensation.
Q6: A patient with COPD is prescribed oxygen therapy. Which delivery device allows the
most precise FiO2 control?
A. Nasal cannula at 4 L/min
B. Simple face mask at 8 L/min
C. Venturi mask with color-coded adapter [CORRECT]
D. Non-rebreather mask at 12 L/min
Correct Answer: C
Rationale: The Venturi mask mixes room air with oxygen using color-coded adapters,
delivering precise FiO2 (24-50%) regardless of breathing pattern. Nasal cannula and
simple mask vary with respiratory rate; non-rebreather delivers high FiO2 but less
precisely. COPD patients often need controlled, low FiO2 to avoid CO2 retention.
Q7: A nurse is opening a sterile package for a wound dressing change. Which action
maintains sterile technique?
A. Opening the package with the flaps away from the sterile field
B. Reaching over the sterile field to retrieve supplies
C. Touching the outer 1-inch border of the sterile drape to position it
D. Turning back to the sterile field after touching the patient's bed rail
, Correct Answer: A
Rationale: Flaps should open away from the sterile field to prevent contamination from
hands/package surfaces. Reaching over, touching the 1-inch border (considered
contaminated), and turning your back to the field all violate sterile principles. Sterile
team members must face the field at all times.
Q8: A patient has a Braden Scale score of 14. Which nursing intervention is most
appropriate?
A. Standard mattress with repositioning every 4 hours
B. Pressure-reducing mattress and repositioning every 2 hours [CORRECT]
C. No special interventions needed; score indicates low risk
D. Massage bony prominences every hour to increase circulation
Correct Answer: B
Rationale: Braden Scale: 15-18 = mild risk, 13-14 = moderate risk, 10-12 = high risk, ≤9 =
very high. Score 14 indicates moderate risk requiring pressure-reducing surfaces and
q2h repositioning. Standard mattress is insufficient; massage doesn't prevent pressure
injury and may damage tissue; the score clearly indicates risk requiring intervention.
Q9: A patient requires restraints for safety. Which nursing action follows best practice?
A. Apply four-point restraints immediately when the patient becomes agitated
B. Use the least restrictive method first, obtain physician order, and monitor every 2
hours [CORRECT]
C. Check the restrained extremities once per shift for circulation
D. Keep restraints applied continuously until discharge to prevent falls
Correct Answer: B
Rationale: Restraint guidelines: (1) Least restrictive alternatives first (verbal
de-escalation, sitters, environmental modifications), (2) Physician order required
(time-limited, typically 24 hours), (3) Frequent monitoring (q2h for adults: circulation,
