NURS 121L-A | Introduction to Medical-Surgical Nursing Practicum |
Module Exam 2 2026 |WCU
1. A nurse is assessing a postoperative patient who just arrived in the PACU.
Which assessment finding should the nurse prioritize first?
A. Report of pain as 7 on a 1-10 scale
B. Oxygen saturation of 88% on room air
C. Urine output of 25 mL in the last hour
D. Serosanguinous drainage on the surgical dressing
Answer: B
Rationale: According to the ABC (Airway, Breathing, Circulation) priority framework, an
oxygen saturation of 88% indicates potential respiratory compromise and must be
addressed immediately.
2. Which action is a primary responsibility of the nurse regarding informed
consent for a surgical procedure?
A. Explaining the risks and benefits of the procedure to the patient
B. Witnessing the patient’s signature on the consent form
C. Describing alternative treatments available to the patient
D. Ensuring the patient understands the surgical technique used
Answer: B
Rationale: The surgeon is responsible for explaining the procedure, risks, and benefits.
The nurse’s role is to witness the signature and ensure the patient is competent to sign.
,3. A patient is 12 hours postoperative following abdominal surgery. The nurse
notes the patient has not voided since surgery. What is the nurse’s first action?
A. Perform a bladder scan
B. Insert a straight catheter immediately
C. Increase the IV fluid rate
D. Notify the healthcare provider
Answer: A
Rationale: A bladder scan is a non-invasive way to assess for urinary retention before
proceeding to invasive interventions like catheterization.
4. The nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which
cardiac monitor finding is most consistent with this lab value?
A. Prominent U waves
B. ST segment depression
C. Tall, peaked T waves
D. Inverted T waves
Answer: C
Rationale: Hyperkalemia (K+ > 5.0) typically manifests as tall, peaked T waves on an ECG.
U waves and ST depression are associated with hypokalemia.
5. While monitoring a patient receiving an IV infusion, the nurse notes the site is
cool, pale, and swollen. What is the nurse’s priority action?
A. Discontinue the IV infusion
B. Slow the infusion rate
C. Apply a warm compress to the site
D. Flush the line with normal saline
Answer: A
Rationale: Coolness, pallor, and swelling are signs of infiltration. The priority is to stop the
infusion and remove the catheter to prevent further tissue damage.
, 6. A patient complains of sudden chest pain and dyspnea on postoperative day
3. What is the most likely complication the nurse should suspect?
A. Pulmonary embolism
B. Atelectasis
C. Hypovolemic shock
D. Pneumonia
Answer: A
Rationale: Sudden onset of chest pain and dyspnea in a postoperative patient are classic
signs of a pulmonary embolism, often resulting from a DVT.
7. Which laboratory value would the nurse prioritize for a patient scheduled for
surgery who is taking warfarin?
A. Hemoglobin and Hematocrit
B. PT/INR
C. Platelet count
D. White blood cell count
Answer: B
Rationale: Warfarin affects blood clotting. PT/INR must be checked to evaluate the risk of
intraoperative and postoperative bleeding.
8. A patient is receiving Patient-Controlled Analgesia (PCA). Which statement by
the patient indicates a need for further teaching?
A. ‘I should push the button when I start to feel pain.’
B. ‘My family can push the button for me if I am too tired.’
C. ‘I will still be able to receive a baseline dose of medicine.’
D. ‘The machine will prevent me from getting too much medicine.’
Answer: B
Rationale: Only the patient should push the PCA button to prevent accidental overdose
and respiratory depression (PCA by proxy is contraindicated).
Module Exam 2 2026 |WCU
1. A nurse is assessing a postoperative patient who just arrived in the PACU.
Which assessment finding should the nurse prioritize first?
A. Report of pain as 7 on a 1-10 scale
B. Oxygen saturation of 88% on room air
C. Urine output of 25 mL in the last hour
D. Serosanguinous drainage on the surgical dressing
Answer: B
Rationale: According to the ABC (Airway, Breathing, Circulation) priority framework, an
oxygen saturation of 88% indicates potential respiratory compromise and must be
addressed immediately.
2. Which action is a primary responsibility of the nurse regarding informed
consent for a surgical procedure?
A. Explaining the risks and benefits of the procedure to the patient
B. Witnessing the patient’s signature on the consent form
C. Describing alternative treatments available to the patient
D. Ensuring the patient understands the surgical technique used
Answer: B
Rationale: The surgeon is responsible for explaining the procedure, risks, and benefits.
The nurse’s role is to witness the signature and ensure the patient is competent to sign.
,3. A patient is 12 hours postoperative following abdominal surgery. The nurse
notes the patient has not voided since surgery. What is the nurse’s first action?
A. Perform a bladder scan
B. Insert a straight catheter immediately
C. Increase the IV fluid rate
D. Notify the healthcare provider
Answer: A
Rationale: A bladder scan is a non-invasive way to assess for urinary retention before
proceeding to invasive interventions like catheterization.
4. The nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which
cardiac monitor finding is most consistent with this lab value?
A. Prominent U waves
B. ST segment depression
C. Tall, peaked T waves
D. Inverted T waves
Answer: C
Rationale: Hyperkalemia (K+ > 5.0) typically manifests as tall, peaked T waves on an ECG.
U waves and ST depression are associated with hypokalemia.
5. While monitoring a patient receiving an IV infusion, the nurse notes the site is
cool, pale, and swollen. What is the nurse’s priority action?
A. Discontinue the IV infusion
B. Slow the infusion rate
C. Apply a warm compress to the site
D. Flush the line with normal saline
Answer: A
Rationale: Coolness, pallor, and swelling are signs of infiltration. The priority is to stop the
infusion and remove the catheter to prevent further tissue damage.
, 6. A patient complains of sudden chest pain and dyspnea on postoperative day
3. What is the most likely complication the nurse should suspect?
A. Pulmonary embolism
B. Atelectasis
C. Hypovolemic shock
D. Pneumonia
Answer: A
Rationale: Sudden onset of chest pain and dyspnea in a postoperative patient are classic
signs of a pulmonary embolism, often resulting from a DVT.
7. Which laboratory value would the nurse prioritize for a patient scheduled for
surgery who is taking warfarin?
A. Hemoglobin and Hematocrit
B. PT/INR
C. Platelet count
D. White blood cell count
Answer: B
Rationale: Warfarin affects blood clotting. PT/INR must be checked to evaluate the risk of
intraoperative and postoperative bleeding.
8. A patient is receiving Patient-Controlled Analgesia (PCA). Which statement by
the patient indicates a need for further teaching?
A. ‘I should push the button when I start to feel pain.’
B. ‘My family can push the button for me if I am too tired.’
C. ‘I will still be able to receive a baseline dose of medicine.’
D. ‘The machine will prevent me from getting too much medicine.’
Answer: B
Rationale: Only the patient should push the PCA button to prevent accidental overdose
and respiratory depression (PCA by proxy is contraindicated).
