NUR 201/NUR201 Exam 2 V1 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is preparing a client for a scheduled elective surgery. Which action is the primary
responsibility of the nurse regarding informed consent?
A. Explaining the risks and benefits of the procedure to the client
B. Witnessing the client’s signature on the consent form
C. Describing alternative treatments available to the client
D. Obtaining the surgical consent from the client
Correct Answer: B
Expert Explanation: The nurse’s role in informed consent is to serve as a witness to the
client’s signature and verify that the client is competent. It is the surgeon’s legal
responsibility to explain the procedure, risks, and alternatives. If the nurse identifies that
the client does not understand the procedure, the surgeon must be notified to provide
further clarification before the form is signed.
2. A client is 4 hours postoperative following an abdominal surgery. Which finding should the
nurse prioritize as the most immediate concern?
A. Pain level of 6 on a 1-10 scale
B. Hypoactive bowel sounds in all quadrants
,C. Urinary output of 100 mL over the last 4 hours
D. Surgical dressing saturated with bright red blood
Correct Answer: D
Expert Explanation: Bright red blood on a surgical dressing indicates active hemorrhage,
which is a life-threatening complication requiring immediate intervention. While pain and
hypoactive bowel sounds are expected postoperatively, they are not immediately life-
threatening. The nurse must assess the patient’s vital signs and notify the surgical team
immediately regarding the excessive bleeding.
3. A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which
clinical manifestation is most characteristic of this condition?
A. Oxygen saturation of 98% on room air
B. Increased anteroposterior chest diameter
C. A sharp, stabbing chest pain upon inspiration
D. Occasional dry, non-productive cough
Correct Answer: B
Expert Explanation: An increased anteroposterior chest diameter, often called a barrel
chest, occurs due to long-term air trapping and hyperinflation of the lungs. COPD clients
typically maintain lower baseline oxygen saturations, and a sharp stabbing pain is more
indicative of pleurisy. The cough in COPD is usually productive and chronic rather than dry
and occasional.
,4. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which cardiac rhythm
change should the nurse monitor for on the EKG?
A. Tall, peaked T waves
B. Presence of U waves
C. Widened QRS complexes
D. Shortened QT interval
Correct Answer: B
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, can lead
to the development of U waves on an EKG. Other changes may include ST-segment
depression and flattened T waves. In contrast, peaked T waves are a hallmark sign of
hyperkalemia, not hypokalemia.
5. A client with a history of hypertension is prescribed a new medication, Lisinopril. Which
side effect should the nurse instruct the client to report immediately?
A. A persistent dry cough
B. Swelling of the lips or tongue
C. Dizziness when standing up quickly
D. Increased frequency of urination
Correct Answer: B
, Expert Explanation: Swelling of the lips, tongue, or throat indicates angioedema, which is
a potentially life-threatening adverse reaction to ACE inhibitors like Lisinopril. While a dry
cough is a common side effect, it is not an emergency. Orthostatic hypotension is also
common, but angioedema requires immediate cessation of the drug and emergency
medical care.
6. During the intraoperative phase, which member of the surgical team is responsible for
maintaining the sterile field and passing instruments?
A. Circulating nurse
B. Anesthesiologist
C. Surgical assistant
D. Scrub nurse
Correct Answer: D
Expert Explanation: The scrub nurse or surgical technologist works within the sterile
field, assists the surgeon, and manages the sterile instruments. The circulating nurse
remains in the unsterile field to coordinate care and document the procedure. Maintaining
the integrity of the sterile environment is a critical safety function of the scrub role.
7. A client is diagnosed with hypocalcemia. Which clinical sign should the nurse expect to find
during the physical assessment?
A. Negative Chvostek’s sign
B. Trousseau’s sign
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is preparing a client for a scheduled elective surgery. Which action is the primary
responsibility of the nurse regarding informed consent?
A. Explaining the risks and benefits of the procedure to the client
B. Witnessing the client’s signature on the consent form
C. Describing alternative treatments available to the client
D. Obtaining the surgical consent from the client
Correct Answer: B
Expert Explanation: The nurse’s role in informed consent is to serve as a witness to the
client’s signature and verify that the client is competent. It is the surgeon’s legal
responsibility to explain the procedure, risks, and alternatives. If the nurse identifies that
the client does not understand the procedure, the surgeon must be notified to provide
further clarification before the form is signed.
2. A client is 4 hours postoperative following an abdominal surgery. Which finding should the
nurse prioritize as the most immediate concern?
A. Pain level of 6 on a 1-10 scale
B. Hypoactive bowel sounds in all quadrants
,C. Urinary output of 100 mL over the last 4 hours
D. Surgical dressing saturated with bright red blood
Correct Answer: D
Expert Explanation: Bright red blood on a surgical dressing indicates active hemorrhage,
which is a life-threatening complication requiring immediate intervention. While pain and
hypoactive bowel sounds are expected postoperatively, they are not immediately life-
threatening. The nurse must assess the patient’s vital signs and notify the surgical team
immediately regarding the excessive bleeding.
3. A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which
clinical manifestation is most characteristic of this condition?
A. Oxygen saturation of 98% on room air
B. Increased anteroposterior chest diameter
C. A sharp, stabbing chest pain upon inspiration
D. Occasional dry, non-productive cough
Correct Answer: B
Expert Explanation: An increased anteroposterior chest diameter, often called a barrel
chest, occurs due to long-term air trapping and hyperinflation of the lungs. COPD clients
typically maintain lower baseline oxygen saturations, and a sharp stabbing pain is more
indicative of pleurisy. The cough in COPD is usually productive and chronic rather than dry
and occasional.
,4. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which cardiac rhythm
change should the nurse monitor for on the EKG?
A. Tall, peaked T waves
B. Presence of U waves
C. Widened QRS complexes
D. Shortened QT interval
Correct Answer: B
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, can lead
to the development of U waves on an EKG. Other changes may include ST-segment
depression and flattened T waves. In contrast, peaked T waves are a hallmark sign of
hyperkalemia, not hypokalemia.
5. A client with a history of hypertension is prescribed a new medication, Lisinopril. Which
side effect should the nurse instruct the client to report immediately?
A. A persistent dry cough
B. Swelling of the lips or tongue
C. Dizziness when standing up quickly
D. Increased frequency of urination
Correct Answer: B
, Expert Explanation: Swelling of the lips, tongue, or throat indicates angioedema, which is
a potentially life-threatening adverse reaction to ACE inhibitors like Lisinopril. While a dry
cough is a common side effect, it is not an emergency. Orthostatic hypotension is also
common, but angioedema requires immediate cessation of the drug and emergency
medical care.
6. During the intraoperative phase, which member of the surgical team is responsible for
maintaining the sterile field and passing instruments?
A. Circulating nurse
B. Anesthesiologist
C. Surgical assistant
D. Scrub nurse
Correct Answer: D
Expert Explanation: The scrub nurse or surgical technologist works within the sterile
field, assists the surgeon, and manages the sterile instruments. The circulating nurse
remains in the unsterile field to coordinate care and document the procedure. Maintaining
the integrity of the sterile environment is a critical safety function of the scrub role.
7. A client is diagnosed with hypocalcemia. Which clinical sign should the nurse expect to find
during the physical assessment?
A. Negative Chvostek’s sign
B. Trousseau’s sign
