NUR 220 | NUR 220 Medical Surgical Nursing Exam
1 Version 2 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A patient arrives in the Post-Anesthesia Care Unit (PACU) following abdominal
surgery. Which nursing assessment is the highest priority?
A. Assessing the surgical dressing for drainage.
B. Checking the patency of the airway and respiratory effort.
C. Measuring the patient’s blood pressure and heart rate.
D. Evaluating the patient’s level of consciousness.
Correct Answer: B
Expert Explanation: Airway management is the primary concern for any patient
recovering from general anesthesia. Respiratory depression or obstruction can
occur rapidly due to residual anesthetic effects or muscle relaxants. Following the
ABC prioritization framework, the nurse must ensure the patient has a patent
airway before assessing circulation or surgical sites. If the airway is compromised,
all other assessments and interventions become secondary to preventing hypoxia.
This systematic approach ensures immediate life-threatening conditions are
identified and managed first.
,2. The nurse is preparing a patient for surgery. Who is legally responsible for obtaining
the patient’s informed consent?
A. The nurse caring for the patient.
B. The surgeon performing the procedure.
C. The hospital administrator.
D. The anesthesiologist.
Correct Answer: B
Expert Explanation: The surgeon is responsible for explaining the procedure, risks,
benefits, and alternatives to the patient. While the nurse may witness the signature,
they do not provide the primary education regarding the surgery itself. If the patient
has questions about the surgery, the nurse must contact the surgeon to return and
clarify. The nurse’s role is to verify that the consent form is signed and that the
patient understands the process. Legally, the provider performing the intervention
holds the ultimate responsibility for the consent process.
3. During surgery, a patient develops tachycardia, muscle rigidity, and a rapidly rising
body temperature. Which medication should the nurse expect to administer
immediately?
A. Dantrolene sodium
B. Epinephrine
,C. Naloxone
D. Atropine sulfate
Correct Answer: A
Expert Explanation: The symptoms described are classic indicators of malignant
hyperthermia, a life-threatening pharmacogenetic disorder. Dantrolene sodium is
the specific skeletal muscle relaxant used to treat this metabolic crisis. It works by
inhibiting calcium release from the sarcoplasmic reticulum, which stops the muscle
rigidity and heat production. The nurse must also anticipate cooling the patient and
providing supportive care for metabolic acidosis. Rapid administration of
dantrolene is crucial to reducing mortality in these emergency situations.
4. A patient is using a Patient-Controlled Analgesia (PCA) pump for post-operative
pain. Which statement by the patient indicates a need for further teaching?
A. I should push the button when I feel the pain starting to increase.
B. My family can push the button for me if I am too tired.
C. The pump won’t let me give myself too much medication.
D. I can still use other pain relief methods like deep breathing.
Correct Answer: B
, Expert Explanation: PCA by proxy, where someone other than the patient pushes
the button, is a significant safety risk. The patient is the only one who can accurately
gauge their pain and level of sedation. If a family member pushes the button while
the patient is sleeping, it could lead to severe respiratory depression. Teaching must
emphasize that the patient is the only individual authorized to operate the device.
Ensuring the patient understands this prevents accidental overdose and promotes
safe pain management.
5. The nurse notes that a post-operative patient’s abdominal wound has eviscerated.
What is the immediate priority action?
A. Gently push the organs back into the abdominal cavity.
B. Place the patient in a High-Fowler’s position.
C. Apply a sterile dressing moistened with sterile normal saline.
D. Notify the surgeon immediately before performing any other action.
Correct Answer: C
Expert Explanation: Evisceration is a medical emergency where internal organs
protrude through a surgical incision. The nurse must immediately cover the exposed
tissue with sterile dressings soaked in sterile saline to keep the organs moist. This
prevents the tissue from drying out and reduces the risk of infection or necrosis.
After covering the wound, the nurse should notify the surgeon and prepare the
1 Version 2 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A patient arrives in the Post-Anesthesia Care Unit (PACU) following abdominal
surgery. Which nursing assessment is the highest priority?
A. Assessing the surgical dressing for drainage.
B. Checking the patency of the airway and respiratory effort.
C. Measuring the patient’s blood pressure and heart rate.
D. Evaluating the patient’s level of consciousness.
Correct Answer: B
Expert Explanation: Airway management is the primary concern for any patient
recovering from general anesthesia. Respiratory depression or obstruction can
occur rapidly due to residual anesthetic effects or muscle relaxants. Following the
ABC prioritization framework, the nurse must ensure the patient has a patent
airway before assessing circulation or surgical sites. If the airway is compromised,
all other assessments and interventions become secondary to preventing hypoxia.
This systematic approach ensures immediate life-threatening conditions are
identified and managed first.
,2. The nurse is preparing a patient for surgery. Who is legally responsible for obtaining
the patient’s informed consent?
A. The nurse caring for the patient.
B. The surgeon performing the procedure.
C. The hospital administrator.
D. The anesthesiologist.
Correct Answer: B
Expert Explanation: The surgeon is responsible for explaining the procedure, risks,
benefits, and alternatives to the patient. While the nurse may witness the signature,
they do not provide the primary education regarding the surgery itself. If the patient
has questions about the surgery, the nurse must contact the surgeon to return and
clarify. The nurse’s role is to verify that the consent form is signed and that the
patient understands the process. Legally, the provider performing the intervention
holds the ultimate responsibility for the consent process.
3. During surgery, a patient develops tachycardia, muscle rigidity, and a rapidly rising
body temperature. Which medication should the nurse expect to administer
immediately?
A. Dantrolene sodium
B. Epinephrine
,C. Naloxone
D. Atropine sulfate
Correct Answer: A
Expert Explanation: The symptoms described are classic indicators of malignant
hyperthermia, a life-threatening pharmacogenetic disorder. Dantrolene sodium is
the specific skeletal muscle relaxant used to treat this metabolic crisis. It works by
inhibiting calcium release from the sarcoplasmic reticulum, which stops the muscle
rigidity and heat production. The nurse must also anticipate cooling the patient and
providing supportive care for metabolic acidosis. Rapid administration of
dantrolene is crucial to reducing mortality in these emergency situations.
4. A patient is using a Patient-Controlled Analgesia (PCA) pump for post-operative
pain. Which statement by the patient indicates a need for further teaching?
A. I should push the button when I feel the pain starting to increase.
B. My family can push the button for me if I am too tired.
C. The pump won’t let me give myself too much medication.
D. I can still use other pain relief methods like deep breathing.
Correct Answer: B
, Expert Explanation: PCA by proxy, where someone other than the patient pushes
the button, is a significant safety risk. The patient is the only one who can accurately
gauge their pain and level of sedation. If a family member pushes the button while
the patient is sleeping, it could lead to severe respiratory depression. Teaching must
emphasize that the patient is the only individual authorized to operate the device.
Ensuring the patient understands this prevents accidental overdose and promotes
safe pain management.
5. The nurse notes that a post-operative patient’s abdominal wound has eviscerated.
What is the immediate priority action?
A. Gently push the organs back into the abdominal cavity.
B. Place the patient in a High-Fowler’s position.
C. Apply a sterile dressing moistened with sterile normal saline.
D. Notify the surgeon immediately before performing any other action.
Correct Answer: C
Expert Explanation: Evisceration is a medical emergency where internal organs
protrude through a surgical incision. The nurse must immediately cover the exposed
tissue with sterile dressings soaked in sterile saline to keep the organs moist. This
prevents the tissue from drying out and reduces the risk of infection or necrosis.
After covering the wound, the nurse should notify the surgeon and prepare the
