NUR 205 Med Surg Exam 1 Version 2 Questions
with Correct Answers and Expert Explanation for
Each Question
1. A nurse is preparing a patient for surgery and notices the patient is confused about
the procedure. Which action should the nurse take regarding informed consent?
A. Explain the risks and benefits of the surgery to the patient.
B. Ask the patient’s spouse to sign the consent form instead.
C. Notify the surgeon that the patient needs further clarification.
D. Proceed with witnessing the signature since the form is already there.
Correct Answer: C
Expert Explanation: The nurse’s primary role in informed consent is to witness the
patient’s signature and verify that they appear competent. It is the surgeon’s legal
responsibility to explain the procedure, risks, and benefits to the patient. If the
patient expresses confusion or lack of understanding, the nurse must advocate for
the patient by contacting the surgeon. The nurse should not attempt to explain the
details of the surgery as this is outside their scope for consent. Ensuring the patient
is fully informed before signing maintains ethical standards and legal compliance.
2. During the preoperative assessment, a patient reports a family history of malignant
hyperthermia. What is the priority nursing action?
A. Monitor the patient’s temperature every 15 minutes.
,B. Administer dantrolene sodium as a prophylactic measure.
C. Notify the anesthesiologist and the surgical team immediately.
D. Instruct the patient to drink plenty of fluids before surgery.
Correct Answer: C
Expert Explanation: Malignant hyperthermia is a rare but life-threatening
inherited muscle disorder triggered by certain volatile anesthetic gases. Notifying
the surgical and anesthesia teams is the priority so they can prepare the proper
equipment and non-triggering agents. While dantrolene is the treatment, it is
typically given once a crisis begins rather than routinely for everyone with a history.
Monitoring temperature is important, but preventing the trigger is the most
effective safety intervention. This history significantly changes the intraoperative
plan to ensure patient safety.
3. A patient has just arrived in the PACU after an abdominal surgery. Which
assessment is the nurse’s highest priority?
A. Assessing the surgical dressing for drainage.
B. Checking the patient’s level of consciousness.
C. Assessing the patency of the patient’s airway.
D. Measuring the patient’s urinary output.
,Correct Answer: C
Expert Explanation: In the immediate postoperative period, the nurse must follow
the ABC (Airway, Breathing, Circulation) framework for prioritization. Maintaining a
patent airway is the most critical step as anesthesia can depress respiratory
function and protective reflexes. Once the airway is secure and breathing is
adequate, the nurse can then assess circulation and surgical sites. Delayed
intervention in airway management can lead to rapid hypoxia and cardiac arrest.
This assessment remains the foundation of safe postanesthesia nursing care.
4. To prevent postoperative pulmonary complications such as atelectasis, which
intervention should the nurse emphasize to the patient?
A. Limiting fluid intake to prevent pulmonary edema.
B. Taking shallow breaths to avoid stressing the incision.
C. Staying in a supine position for the first 24 hours.
D. Using the incentive spirometer 10 times every hour while awake.
Correct Answer: D
Expert Explanation: Incentive spirometry encourages deep breathing and lung
expansion, which helps keep the alveoli open and prevents collapse. Atelectasis is a
common postoperative complication that can lead to pneumonia if not addressed
early. Patients should be taught to use the device regularly and to perform coughing
, and deep breathing exercises. Adequate pain control is often necessary to allow the
patient to perform these respiratory exercises effectively. These interventions
facilitate optimal gas exchange and speed up the recovery process.
5. A nurse observes a loop of bowel protruding from a patient’s abdominal incision.
Which action should the nurse perform first?
A. Push the bowel gently back into the abdominal cavity.
B. Cover the protruding organ with sterile gauze soaked in normal saline.
C. Assess the patient’s vital signs and call the surgeon.
D. Place the patient in a high-Fowler’s position immediately.
Correct Answer: B
Expert Explanation: Wound evisceration is a surgical emergency where internal
organs protrude through a dehisced incision. The nurse must immediately cover the
exposed tissue with sterile, saline-soaked dressings to keep it moist and prevent
necrosis. The nurse should then call for help and notify the surgeon while keeping
the patient still in a low-Fowler’s position with knees flexed. Attempting to reinsert
the bowel is dangerous and can cause further injury or infection. This rapid
response is vital to preserve organ function and prepare for emergency surgery.
with Correct Answers and Expert Explanation for
Each Question
1. A nurse is preparing a patient for surgery and notices the patient is confused about
the procedure. Which action should the nurse take regarding informed consent?
A. Explain the risks and benefits of the surgery to the patient.
B. Ask the patient’s spouse to sign the consent form instead.
C. Notify the surgeon that the patient needs further clarification.
D. Proceed with witnessing the signature since the form is already there.
Correct Answer: C
Expert Explanation: The nurse’s primary role in informed consent is to witness the
patient’s signature and verify that they appear competent. It is the surgeon’s legal
responsibility to explain the procedure, risks, and benefits to the patient. If the
patient expresses confusion or lack of understanding, the nurse must advocate for
the patient by contacting the surgeon. The nurse should not attempt to explain the
details of the surgery as this is outside their scope for consent. Ensuring the patient
is fully informed before signing maintains ethical standards and legal compliance.
2. During the preoperative assessment, a patient reports a family history of malignant
hyperthermia. What is the priority nursing action?
A. Monitor the patient’s temperature every 15 minutes.
,B. Administer dantrolene sodium as a prophylactic measure.
C. Notify the anesthesiologist and the surgical team immediately.
D. Instruct the patient to drink plenty of fluids before surgery.
Correct Answer: C
Expert Explanation: Malignant hyperthermia is a rare but life-threatening
inherited muscle disorder triggered by certain volatile anesthetic gases. Notifying
the surgical and anesthesia teams is the priority so they can prepare the proper
equipment and non-triggering agents. While dantrolene is the treatment, it is
typically given once a crisis begins rather than routinely for everyone with a history.
Monitoring temperature is important, but preventing the trigger is the most
effective safety intervention. This history significantly changes the intraoperative
plan to ensure patient safety.
3. A patient has just arrived in the PACU after an abdominal surgery. Which
assessment is the nurse’s highest priority?
A. Assessing the surgical dressing for drainage.
B. Checking the patient’s level of consciousness.
C. Assessing the patency of the patient’s airway.
D. Measuring the patient’s urinary output.
,Correct Answer: C
Expert Explanation: In the immediate postoperative period, the nurse must follow
the ABC (Airway, Breathing, Circulation) framework for prioritization. Maintaining a
patent airway is the most critical step as anesthesia can depress respiratory
function and protective reflexes. Once the airway is secure and breathing is
adequate, the nurse can then assess circulation and surgical sites. Delayed
intervention in airway management can lead to rapid hypoxia and cardiac arrest.
This assessment remains the foundation of safe postanesthesia nursing care.
4. To prevent postoperative pulmonary complications such as atelectasis, which
intervention should the nurse emphasize to the patient?
A. Limiting fluid intake to prevent pulmonary edema.
B. Taking shallow breaths to avoid stressing the incision.
C. Staying in a supine position for the first 24 hours.
D. Using the incentive spirometer 10 times every hour while awake.
Correct Answer: D
Expert Explanation: Incentive spirometry encourages deep breathing and lung
expansion, which helps keep the alveoli open and prevents collapse. Atelectasis is a
common postoperative complication that can lead to pneumonia if not addressed
early. Patients should be taught to use the device regularly and to perform coughing
, and deep breathing exercises. Adequate pain control is often necessary to allow the
patient to perform these respiratory exercises effectively. These interventions
facilitate optimal gas exchange and speed up the recovery process.
5. A nurse observes a loop of bowel protruding from a patient’s abdominal incision.
Which action should the nurse perform first?
A. Push the bowel gently back into the abdominal cavity.
B. Cover the protruding organ with sterile gauze soaked in normal saline.
C. Assess the patient’s vital signs and call the surgeon.
D. Place the patient in a high-Fowler’s position immediately.
Correct Answer: B
Expert Explanation: Wound evisceration is a surgical emergency where internal
organs protrude through a dehisced incision. The nurse must immediately cover the
exposed tissue with sterile, saline-soaked dressings to keep it moist and prevent
necrosis. The nurse should then call for help and notify the surgeon while keeping
the patient still in a low-Fowler’s position with knees flexed. Attempting to reinsert
the bowel is dangerous and can cause further injury or infection. This rapid
response is vital to preserve organ function and prepare for emergency surgery.
