NURS 120 | NURS120 Exam 1: Med Surg 1 - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is performing an initial assessment on a patient. Which of the following is
considered subjective data?
A. Blood pressure reading of 140/90 mmHg
B. Presence of a 2 cm skin lesion on the arm
C. Client’s report of a sharp pain in the lower back
D. Pitting edema in the lower extremities
Correct Answer: C
Rationale: Subjective data consists of information that the patient describes about their
own feelings or sensations. Pain is a classic example because it cannot be seen or measured
directly by the nurse. Objective data includes measurable findings like blood pressure or
physical observations like edema. The nurse must document subjective data using the
patient’s own words to ensure accuracy. This distinction is critical for developing a patient-
centered care plan based on the individual’s experience.
2. In which order should the nurse perform an abdominal physical assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Rationale: The abdominal assessment requires a specific sequence to avoid altering
clinical findings. Inspection is always first to observe the surface for any abnormalities.
Auscultation must follow inspection because palpating or percussing the abdomen can
stimulate bowel sounds. If the nurse percusses first, they may hear hyperactive sounds that
are not naturally occurring. Following this specific order ensures that the assessment of
bowel activity is as accurate as possible.
3. A patient is admitted with suspected tuberculosis (TB). Which type of precautions should
the nurse implement?
A. Airborne Precautions
B. Droplet Precautions
C. Contact Precautions
,D. Standard Precautions only
Correct Answer: A
Rationale: Airborne precautions are required for diseases transmitted by small droplets
that remain suspended in the air. Tuberculosis is a primary example of a pathogen that
requires a negative-pressure room and specialized masks. The nurse must wear an N95
respirator before entering the room to prevent inhalation of the bacteria. Standard
precautions are always used, but they are insufficient for the specific risks associated with
TB. Proper isolation prevents the spread of the infection to healthcare workers and other
patients in the facility.
4. A nurse is caring for an older adult patient who is at high risk for falls. Which intervention is
the priority?
A. Apply soft wrist restraints to prevent the patient from getting up
B. Place the call light within the patient’s reach
C. Keep all four side rails up at all times
D. Administer a sedative to keep the patient in bed
Correct Answer: B
Rationale: Safety interventions should always prioritize the least restrictive measures
first. Placing the call light within reach allows the patient to request assistance before
attempting to move. Using all four side rails or restraints is often considered a form of false
imprisonment and can increase the risk of injury. Sedatives are not appropriate fall
prevention strategies as they can cause confusion and gait instability. Ensuring the patient
has the tools to call for help is a fundamental nursing responsibility in fall prevention.
5. When washing hands with soap and water, what is the minimum recommended duration
for scrubbing?
A. 20 seconds
B. 10 seconds
C. 5 seconds
D. 60 seconds
Correct Answer: A
Rationale: The Centers for Disease Control (CDC) recommends scrubbing hands for at
least 20 seconds to effectively remove pathogens. Friction is the most important element of
hand washing for mechanical removal of microorganisms. The nurse should ensure all
surfaces of the hands, including between fingers and under nails, are cleaned. While longer
scrubbing may be necessary for visible soil, 20 seconds is the standard for routine care.
Proper hand hygiene is the single most effective way to prevent the spread of healthcare-
associated infections.
, 6. A patient has a serum potassium level of 6.2 mEq/L. Which finding should the nurse
prioritize for assessment?
A. Cardiac rhythm changes on the monitor
B. Hyperactive bowel sounds
C. Increased urinary output
D. Dry mucous membranes
Correct Answer: A
Rationale: Potassium levels above 5.0 mEq/L indicate hyperkalemia, which significantly
impacts cardiac electrical conduction. A level of 6.2 is dangerously high and can lead to life-
threatening arrhythmias or cardiac arrest. The nurse must immediately monitor the ECG
for peaked T waves or a widened QRS complex. While other symptoms like muscle
weakness or GI changes may occur, cardiac stability is the primary concern. Timely
intervention is required to lower potassium levels and protect the heart muscle.
7. Which action by the nurse maintains the sterility of a sterile field?
A. Reaching across the sterile field to pick up a tool
B. Placing a sterile bottle cap face down on a clean table
C. Turning one’s back to the sterile field to grab supplies
D. Keeping the sterile field within the line of vision
Correct Answer: D
Rationale: A sterile field must always be kept within the nurse’s line of sight to ensure no
contamination occurs. If the nurse turns their back or leaves the field, they can no longer
guarantee its sterility. Reaching over the field is a violation because microorganisms from
the nurse’s clothing can fall onto the sterile area. Sterile items must also be kept above the
waist to be considered safe. These strict protocols are essential for preventing surgical site
infections and maintaining patient safety.
8. A nurse is teaching a postoperative patient how to use an incentive spirometer. What is
the primary purpose of this device?
A. To measure the patient’s oxygen saturation levels
B. To strengthen the abdominal muscles used for coughing
C. To promote deep breathing and prevent atelectasis
D. To decrease the amount of oxygen required by the patient
Correct Answer: C
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is performing an initial assessment on a patient. Which of the following is
considered subjective data?
A. Blood pressure reading of 140/90 mmHg
B. Presence of a 2 cm skin lesion on the arm
C. Client’s report of a sharp pain in the lower back
D. Pitting edema in the lower extremities
Correct Answer: C
Rationale: Subjective data consists of information that the patient describes about their
own feelings or sensations. Pain is a classic example because it cannot be seen or measured
directly by the nurse. Objective data includes measurable findings like blood pressure or
physical observations like edema. The nurse must document subjective data using the
patient’s own words to ensure accuracy. This distinction is critical for developing a patient-
centered care plan based on the individual’s experience.
2. In which order should the nurse perform an abdominal physical assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Rationale: The abdominal assessment requires a specific sequence to avoid altering
clinical findings. Inspection is always first to observe the surface for any abnormalities.
Auscultation must follow inspection because palpating or percussing the abdomen can
stimulate bowel sounds. If the nurse percusses first, they may hear hyperactive sounds that
are not naturally occurring. Following this specific order ensures that the assessment of
bowel activity is as accurate as possible.
3. A patient is admitted with suspected tuberculosis (TB). Which type of precautions should
the nurse implement?
A. Airborne Precautions
B. Droplet Precautions
C. Contact Precautions
,D. Standard Precautions only
Correct Answer: A
Rationale: Airborne precautions are required for diseases transmitted by small droplets
that remain suspended in the air. Tuberculosis is a primary example of a pathogen that
requires a negative-pressure room and specialized masks. The nurse must wear an N95
respirator before entering the room to prevent inhalation of the bacteria. Standard
precautions are always used, but they are insufficient for the specific risks associated with
TB. Proper isolation prevents the spread of the infection to healthcare workers and other
patients in the facility.
4. A nurse is caring for an older adult patient who is at high risk for falls. Which intervention is
the priority?
A. Apply soft wrist restraints to prevent the patient from getting up
B. Place the call light within the patient’s reach
C. Keep all four side rails up at all times
D. Administer a sedative to keep the patient in bed
Correct Answer: B
Rationale: Safety interventions should always prioritize the least restrictive measures
first. Placing the call light within reach allows the patient to request assistance before
attempting to move. Using all four side rails or restraints is often considered a form of false
imprisonment and can increase the risk of injury. Sedatives are not appropriate fall
prevention strategies as they can cause confusion and gait instability. Ensuring the patient
has the tools to call for help is a fundamental nursing responsibility in fall prevention.
5. When washing hands with soap and water, what is the minimum recommended duration
for scrubbing?
A. 20 seconds
B. 10 seconds
C. 5 seconds
D. 60 seconds
Correct Answer: A
Rationale: The Centers for Disease Control (CDC) recommends scrubbing hands for at
least 20 seconds to effectively remove pathogens. Friction is the most important element of
hand washing for mechanical removal of microorganisms. The nurse should ensure all
surfaces of the hands, including between fingers and under nails, are cleaned. While longer
scrubbing may be necessary for visible soil, 20 seconds is the standard for routine care.
Proper hand hygiene is the single most effective way to prevent the spread of healthcare-
associated infections.
, 6. A patient has a serum potassium level of 6.2 mEq/L. Which finding should the nurse
prioritize for assessment?
A. Cardiac rhythm changes on the monitor
B. Hyperactive bowel sounds
C. Increased urinary output
D. Dry mucous membranes
Correct Answer: A
Rationale: Potassium levels above 5.0 mEq/L indicate hyperkalemia, which significantly
impacts cardiac electrical conduction. A level of 6.2 is dangerously high and can lead to life-
threatening arrhythmias or cardiac arrest. The nurse must immediately monitor the ECG
for peaked T waves or a widened QRS complex. While other symptoms like muscle
weakness or GI changes may occur, cardiac stability is the primary concern. Timely
intervention is required to lower potassium levels and protect the heart muscle.
7. Which action by the nurse maintains the sterility of a sterile field?
A. Reaching across the sterile field to pick up a tool
B. Placing a sterile bottle cap face down on a clean table
C. Turning one’s back to the sterile field to grab supplies
D. Keeping the sterile field within the line of vision
Correct Answer: D
Rationale: A sterile field must always be kept within the nurse’s line of sight to ensure no
contamination occurs. If the nurse turns their back or leaves the field, they can no longer
guarantee its sterility. Reaching over the field is a violation because microorganisms from
the nurse’s clothing can fall onto the sterile area. Sterile items must also be kept above the
waist to be considered safe. These strict protocols are essential for preventing surgical site
infections and maintaining patient safety.
8. A nurse is teaching a postoperative patient how to use an incentive spirometer. What is
the primary purpose of this device?
A. To measure the patient’s oxygen saturation levels
B. To strengthen the abdominal muscles used for coughing
C. To promote deep breathing and prevent atelectasis
D. To decrease the amount of oxygen required by the patient
Correct Answer: C
