NUR 201/NUR201 Exam 4 V2 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A patient with a newly applied plaster cast for a tibia fracture reports severe, increasing
pain that is not relieved by the prescribed analgesic. What is the nurse’s priority action?
A. Apply ice packs to the cast surface to reduce swelling.
B. Perform a neurovascular assessment of the affected extremity.
C. Elevate the affected leg above the level of the heart.
D. Instruct the patient to perform range-of-motion exercises with the toes.
Correct Answer: B
Expert Explanation: Unrelieved pain after analgesia in a casted patient is a hallmark sign
of compartment syndrome. The nurse must immediately perform a neurovascular
assessment to check for the six P’s (pain, pressure, paralysis, paresthesia, pallor, and
pulselessness). Prompt identification is critical to prevent permanent tissue damage or
limb loss.
2. A patient is scheduled for a total hip arthroplasty. Which preoperative medication should
the nurse expect the surgeon to discontinue at least one week prior to surgery?
A. Acetaminophen
B. Vitamin D
,C. Lisinopril
D. Aspirin
Correct Answer: D
Expert Explanation: Aspirin inhibits platelet aggregation and increases the risk of
perioperative hemorrhage. It is typically discontinued at least 7 to 10 days before elective
surgeries like hip replacement. Other NSAIDs may also be held depending on the surgeon’s
specific protocol.
3. When caring for a patient in Buck’s skin traction, which nursing intervention is essential to
maintain effective traction?
A. Ensuring the weights hang freely and do not touch the floor.
B. Allowing the weights to rest on the floor when the patient is sleeping.
C. Removing the weights once per shift to inspect the skin.
D. Tying the knots in the rope against the pulley system.
Correct Answer: A
Expert Explanation: For traction to be effective, the weights must hang freely and never
touch the floor. If weights are resting on the floor, the tension is lost, and the purpose of the
traction is defeated. The nurse must also ensure that ropes are not frayed and that the
patient is properly aligned in the center of the bed.
, 4. A nurse is providing discharge instructions to a patient with osteoporosis who has been
prescribed Alendronate (Fosamax). Which instruction is most important?
A. Take the medication with a full glass of milk.
B. Take the medication first thing in the morning on an empty stomach.
C. Lie down for 30 minutes after taking the medication to rest.
D. Wait at least 10 minutes after taking the dose before eating breakfast.
Correct Answer: B
Expert Explanation: Alendronate must be taken on an empty stomach with a full glass of
plain water to ensure absorption. The patient must remain upright (sitting or standing) for
at least 30 minutes after ingestion to prevent esophageal irritation or ulceration. Taking it
with food, juice, or coffee significantly reduces the drug’s effectiveness.
5. The nurse is assessing a patient with a T6 spinal cord injury who reports a sudden, severe
headache and nasal congestion. The patient’s blood pressure is 185/105 mmHg. What is the
priority nursing action?
A. Check the patient’s urinary catheter for kinks or obstruction.
B. Sit the patient upright and lower the head of the bed.
C. Administer the prescribed PRN dose of hydralazine.
D. Perform a digital rectal exam to check for fecal impaction.
Correct Answer: A
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A patient with a newly applied plaster cast for a tibia fracture reports severe, increasing
pain that is not relieved by the prescribed analgesic. What is the nurse’s priority action?
A. Apply ice packs to the cast surface to reduce swelling.
B. Perform a neurovascular assessment of the affected extremity.
C. Elevate the affected leg above the level of the heart.
D. Instruct the patient to perform range-of-motion exercises with the toes.
Correct Answer: B
Expert Explanation: Unrelieved pain after analgesia in a casted patient is a hallmark sign
of compartment syndrome. The nurse must immediately perform a neurovascular
assessment to check for the six P’s (pain, pressure, paralysis, paresthesia, pallor, and
pulselessness). Prompt identification is critical to prevent permanent tissue damage or
limb loss.
2. A patient is scheduled for a total hip arthroplasty. Which preoperative medication should
the nurse expect the surgeon to discontinue at least one week prior to surgery?
A. Acetaminophen
B. Vitamin D
,C. Lisinopril
D. Aspirin
Correct Answer: D
Expert Explanation: Aspirin inhibits platelet aggregation and increases the risk of
perioperative hemorrhage. It is typically discontinued at least 7 to 10 days before elective
surgeries like hip replacement. Other NSAIDs may also be held depending on the surgeon’s
specific protocol.
3. When caring for a patient in Buck’s skin traction, which nursing intervention is essential to
maintain effective traction?
A. Ensuring the weights hang freely and do not touch the floor.
B. Allowing the weights to rest on the floor when the patient is sleeping.
C. Removing the weights once per shift to inspect the skin.
D. Tying the knots in the rope against the pulley system.
Correct Answer: A
Expert Explanation: For traction to be effective, the weights must hang freely and never
touch the floor. If weights are resting on the floor, the tension is lost, and the purpose of the
traction is defeated. The nurse must also ensure that ropes are not frayed and that the
patient is properly aligned in the center of the bed.
, 4. A nurse is providing discharge instructions to a patient with osteoporosis who has been
prescribed Alendronate (Fosamax). Which instruction is most important?
A. Take the medication with a full glass of milk.
B. Take the medication first thing in the morning on an empty stomach.
C. Lie down for 30 minutes after taking the medication to rest.
D. Wait at least 10 minutes after taking the dose before eating breakfast.
Correct Answer: B
Expert Explanation: Alendronate must be taken on an empty stomach with a full glass of
plain water to ensure absorption. The patient must remain upright (sitting or standing) for
at least 30 minutes after ingestion to prevent esophageal irritation or ulceration. Taking it
with food, juice, or coffee significantly reduces the drug’s effectiveness.
5. The nurse is assessing a patient with a T6 spinal cord injury who reports a sudden, severe
headache and nasal congestion. The patient’s blood pressure is 185/105 mmHg. What is the
priority nursing action?
A. Check the patient’s urinary catheter for kinks or obstruction.
B. Sit the patient upright and lower the head of the bed.
C. Administer the prescribed PRN dose of hydralazine.
D. Perform a digital rectal exam to check for fecal impaction.
Correct Answer: A
