NUR 101 Exam 4 / Final Exam Review – Health
Assessment (100% Correct | Verified Solutions) –
Fortis 7 PARTS EXAM 100 QUESTIONS AND
ANSWERS ALREADY GRADED A+
Section 1: Perioperative Nursing
1. A patient is scheduled for surgery in 2 hours. The nurse is reviewing the pre-
operative checklist. Which finding requires the nurse to notify the surgeon
immediately?
a) The patient's blood pressure is 138/86 mmHg.
b) The patient has a history of smoking.
c) The patient ate a light breakfast 1 hour ago.
d) The patient reports feeling anxious.
Answer: c
Rationale: The patient is NPO (nothing by mouth) before surgery to prevent
aspiration. Eating 1 hour pre-op violates NPO status and the surgery may need to
be postponed. The surgeon must be notified immediately. Anxiety is normal and
should be addressed, but it is not an emergency. Slightly elevated BP is common
with anxiety and may be reassessed.
2. A patient is in the post-anesthesia care unit (PACU) after surgery. The nurse
notes that the patient's oxygen saturation is 89% on room air. What is the
nurse's priority action?
a) Document the finding and recheck in 15 minutes.
b) Administer oxygen and encourage deep breathing.
c) Notify the surgeon immediately.
,d) Place the patient in a supine position.
Answer: b
Rationale: An SpO2 of 89% indicates hypoxemia. The nurse's priority is
to administer oxygen and position the patient in high-Fowler's to promote lung
expansion. The provider should be notified if the patient does not improve.
Documentation comes after intervention.
3. A patient is 1 hour post-operative from abdominal surgery. The nurse assesses
the surgical dressing and notes a small amount of serosanguinous drainage.
Which action is correct?
a) Remove the dressing and inspect the wound.
b) Mark the drainage on the dressing and continue to monitor.
c) Notify the surgeon immediately.
d) Apply a pressure dressing.
Answer: b
Rationale: A small amount of serosanguinous (pink/watery) drainage is normal in
the early post-operative period. The nurse should mark the drainage with a
pen and continue to monitor for increased bleeding. If the drainage becomes
bright red and saturates the dressing, the surgeon should be notified.
4. A patient is being discharged after surgery. The nurse is teaching about
incision care. Which statement by the patient indicates a need for further
teaching?
a) "I will keep the incision clean and dry."
b) "I will call the doctor if I see redness, swelling, or drainage."
c) "I can take a bath and soak the incision to keep it clean."
d) "I will report a fever over 101°F."
Answer: c
Rationale: The patient should not submerge the incision in water (bath, pool, hot
tub) until the sutures/staples are removed and the incision is fully healed, as this
,increases the risk of infection. Sponge baths or showers (with a waterproof
dressing) are preferred. The other options are correct.
5. The nurse is assessing a patient's surgical wound on post-operative day 3. The
wound edges are separated and the nurse can see the underlying tissue layers.
This condition is called:
a) Evisceration
b) Dehiscence
c) Hematoma
d) Seroma
Answer: b
Rationale: Dehiscence is the partial or complete separation of wound layers. If the
wound edges separate and organs protrude, it is called evisceration (a surgical
emergency). A hematoma is a collection of blood; a seroma is a collection of
serous fluid.
6. A patient experiences sudden, profuse bleeding from a surgical wound, and
the wound edges open, exposing abdominal organs. What is the nurse's priority
action?
a) Apply a dry sterile dressing.
b) Cover the exposed organs with sterile, saline-soaked gauze and call for help.
c) Push the organs back into the abdomen.
d) Place the patient in a high-Fowler's position.
Answer: b
Rationale: This is evisceration, a surgical emergency. The nurse should cover the
exposed organs with sterile saline-soaked gauze, keep the patient in a low-
Fowler's position with knees bent, and notify the surgeon immediately. Never
push organs back in – that is done by the surgeon in the OR.
, 7. A patient is receiving morphine via patient-controlled analgesia (PCA). The
nurse assesses the patient's respiratory rate and finds it to be 8 breaths per
minute. What should the nurse do first?
a) Increase the PCA dose.
b) Stimulate the patient to breathe and administer naloxone (Narcan) as ordered.
c) Turn off the PCA and continue to monitor.
d) Notify the family.
Answer: b
Rationale: A respiratory rate of 8 indicates opioid-induced respiratory depression.
The nurse should stimulate the patient to breathe, administer naloxone (the
opioid antagonist) per protocol/order, and notify the provider. The PCA should
be paused. Naloxone reverses respiratory depression.
8. The nurse is performing a pre-operative assessment on a patient who reports
taking herbal supplements, including ginseng and garlic. Which is the primary
concern with these supplements before surgery?
a) They can cause hypoglycemia.
b) They can increase the risk of bleeding.
c) They can cause allergic reactions.
d) They can cause hypertension.
Answer: b
Rationale: Garlic and ginseng (along with ginkgo, fish oil, and vitamin E)
can increase the risk of bleeding by affecting platelet function. The patient should
stop these supplements at least 1–2 weeks before surgery (per provider's orders).
This is a key pre-operative teaching point.
9. A patient is post-operative and has a Jackson-Pratt (JP) drain. The nurse
empties the drain and records 50 mL of sanguineous drainage. The nurse should:
a) Document the amount and recompress the bulb to maintain suction.
b) Notify the surgeon because 50 mL is too much.
c) Discard the drainage without measuring.
Assessment (100% Correct | Verified Solutions) –
Fortis 7 PARTS EXAM 100 QUESTIONS AND
ANSWERS ALREADY GRADED A+
Section 1: Perioperative Nursing
1. A patient is scheduled for surgery in 2 hours. The nurse is reviewing the pre-
operative checklist. Which finding requires the nurse to notify the surgeon
immediately?
a) The patient's blood pressure is 138/86 mmHg.
b) The patient has a history of smoking.
c) The patient ate a light breakfast 1 hour ago.
d) The patient reports feeling anxious.
Answer: c
Rationale: The patient is NPO (nothing by mouth) before surgery to prevent
aspiration. Eating 1 hour pre-op violates NPO status and the surgery may need to
be postponed. The surgeon must be notified immediately. Anxiety is normal and
should be addressed, but it is not an emergency. Slightly elevated BP is common
with anxiety and may be reassessed.
2. A patient is in the post-anesthesia care unit (PACU) after surgery. The nurse
notes that the patient's oxygen saturation is 89% on room air. What is the
nurse's priority action?
a) Document the finding and recheck in 15 minutes.
b) Administer oxygen and encourage deep breathing.
c) Notify the surgeon immediately.
,d) Place the patient in a supine position.
Answer: b
Rationale: An SpO2 of 89% indicates hypoxemia. The nurse's priority is
to administer oxygen and position the patient in high-Fowler's to promote lung
expansion. The provider should be notified if the patient does not improve.
Documentation comes after intervention.
3. A patient is 1 hour post-operative from abdominal surgery. The nurse assesses
the surgical dressing and notes a small amount of serosanguinous drainage.
Which action is correct?
a) Remove the dressing and inspect the wound.
b) Mark the drainage on the dressing and continue to monitor.
c) Notify the surgeon immediately.
d) Apply a pressure dressing.
Answer: b
Rationale: A small amount of serosanguinous (pink/watery) drainage is normal in
the early post-operative period. The nurse should mark the drainage with a
pen and continue to monitor for increased bleeding. If the drainage becomes
bright red and saturates the dressing, the surgeon should be notified.
4. A patient is being discharged after surgery. The nurse is teaching about
incision care. Which statement by the patient indicates a need for further
teaching?
a) "I will keep the incision clean and dry."
b) "I will call the doctor if I see redness, swelling, or drainage."
c) "I can take a bath and soak the incision to keep it clean."
d) "I will report a fever over 101°F."
Answer: c
Rationale: The patient should not submerge the incision in water (bath, pool, hot
tub) until the sutures/staples are removed and the incision is fully healed, as this
,increases the risk of infection. Sponge baths or showers (with a waterproof
dressing) are preferred. The other options are correct.
5. The nurse is assessing a patient's surgical wound on post-operative day 3. The
wound edges are separated and the nurse can see the underlying tissue layers.
This condition is called:
a) Evisceration
b) Dehiscence
c) Hematoma
d) Seroma
Answer: b
Rationale: Dehiscence is the partial or complete separation of wound layers. If the
wound edges separate and organs protrude, it is called evisceration (a surgical
emergency). A hematoma is a collection of blood; a seroma is a collection of
serous fluid.
6. A patient experiences sudden, profuse bleeding from a surgical wound, and
the wound edges open, exposing abdominal organs. What is the nurse's priority
action?
a) Apply a dry sterile dressing.
b) Cover the exposed organs with sterile, saline-soaked gauze and call for help.
c) Push the organs back into the abdomen.
d) Place the patient in a high-Fowler's position.
Answer: b
Rationale: This is evisceration, a surgical emergency. The nurse should cover the
exposed organs with sterile saline-soaked gauze, keep the patient in a low-
Fowler's position with knees bent, and notify the surgeon immediately. Never
push organs back in – that is done by the surgeon in the OR.
, 7. A patient is receiving morphine via patient-controlled analgesia (PCA). The
nurse assesses the patient's respiratory rate and finds it to be 8 breaths per
minute. What should the nurse do first?
a) Increase the PCA dose.
b) Stimulate the patient to breathe and administer naloxone (Narcan) as ordered.
c) Turn off the PCA and continue to monitor.
d) Notify the family.
Answer: b
Rationale: A respiratory rate of 8 indicates opioid-induced respiratory depression.
The nurse should stimulate the patient to breathe, administer naloxone (the
opioid antagonist) per protocol/order, and notify the provider. The PCA should
be paused. Naloxone reverses respiratory depression.
8. The nurse is performing a pre-operative assessment on a patient who reports
taking herbal supplements, including ginseng and garlic. Which is the primary
concern with these supplements before surgery?
a) They can cause hypoglycemia.
b) They can increase the risk of bleeding.
c) They can cause allergic reactions.
d) They can cause hypertension.
Answer: b
Rationale: Garlic and ginseng (along with ginkgo, fish oil, and vitamin E)
can increase the risk of bleeding by affecting platelet function. The patient should
stop these supplements at least 1–2 weeks before surgery (per provider's orders).
This is a key pre-operative teaching point.
9. A patient is post-operative and has a Jackson-Pratt (JP) drain. The nurse
empties the drain and records 50 mL of sanguineous drainage. The nurse should:
a) Document the amount and recompress the bulb to maintain suction.
b) Notify the surgeon because 50 mL is too much.
c) Discard the drainage without measuring.
