,NU 131 — Exam 1 Comprehensive Questions
& Verified Answers | 2026 Edition
1. Which of the following best describes the primary purpose of surgical hand antisepsis?
A) To sterilize the hands and forearms completely
B) To reduce the resident microbial flora to a minimum and eliminate transient flora
C) To remove all visible soil from the hands
D) To moisturize the skin before gloving
Correct Answer: To reduce the resident microbial flora to a minimum and eliminate transient flora
Rationale: Surgical hand antisepsis uses antimicrobial agents and prolonged scrubbing to decrease both
transient and resident microorganisms on the skin. Complete sterilization of living skin is not achievable.
Removing visible soil is for routine handwashing, and moisturizing is a skin care, not antiseptic, function.
2. The nurse is preparing a patient for surgery and notes that the informed consent form is signed but
the patient does not understand the risks of the procedure. The nurse should
A) proceed with preoperative preparation
B) notify the surgeon and document the patient's lack of understanding
C) explain the risks again and have the patient sign a new form
D) cancel the surgery without notifying the surgeon
Correct Answer: Notify the surgeon and document the patient's lack of understanding
Rationale: The surgeon performing the procedure is responsible for obtaining informed consent. If the
patient does not understand risks, the nurse must notify the surgeon, who must clarify before the
patient can give valid consent. The nurse can witness but not obtain consent.
3. The nurse is caring for a patient who received preoperative sedation. The patient is now drowsy but
arousable. The nurse should
A) allow the patient to ambulate to the bathroom
,B) raise all four side rails for maximum safety
C) maintain the bed in the lowest position and keep side rails raised per policy
D) place the patient in a semi-Fowler's position without side rails
Correct Answer: Maintain the bed in the lowest position and keep side rails raised per policy
Rationale: A sedated patient is a fall risk. The bed should be in the lowest position, with side rails raised
according to facility policy (usually two or three). Raising all four rails may constitute a restraint.
Ambulation is unsafe until sedation resolves.
4. During the intraoperative phase, the nurse identifies that a patient's position on the operating table
places the patient at risk for injury to the brachial plexus. Which position is most associated with this
risk?
A) Supine with arms padded at the sides
B) Trendelenburg with shoulder braces
C) Lithotomy with legs in stirrups
D) Prone with chest rolls
Correct Answer: Trendelenburg with shoulder braces
Rationale: Shoulder braces used in Trendelenburg position can compress the brachial plexus if placed
incorrectly, causing nerve injury. Supine with padded arms, lithotomy, and prone with chest rolls have
different risk profiles but brachial plexus injury is classic with shoulder braces.
5. The postanesthesia care unit (PACU) nurse is assessing a patient who has just undergone general
anesthesia. Which assessment finding requires immediate intervention?
A) Respiratory rate of 12 breaths per minute
B) Oxygen saturation of 92% on room air
C) Stridor and intercostal retractions
D) Temperature of 96.8°F (36°C)
, Correct Answer: Stridor and intercostal retractions
Rationale: Stridor and retractions indicate upper airway obstruction or laryngeal edema, a life-
threatening complication. Immediate intervention is needed to secure the airway. A rate of 12,
saturation 92% (which may need oxygen), and mild hypothermia are less urgent.
6. The nurse is monitoring a patient in the PACU who suddenly develops a drop in oxygen saturation to
85% and has gurgling respirations. The first action is to
A) administer naloxone
B) call a code blue
C) suction the airway and reposition the head
D) increase IV fluids
Correct Answer: Suction the airway and reposition the head
Rationale: Gurgling indicates secretions in the airway. Suctioning and repositioning (chin lift, jaw thrust)
may rapidly resolve the obstruction. Naloxone is for respiratory depression from opioids. Increasing
fluids does not address airway obstruction.
7. The nurse is caring for a postoperative patient who has not voided in 8 hours after surgery. The
bladder is distended. The first nursing action is to
A) insert an indwelling catheter
B) provide privacy and pour warm water over the perineum
C) administer a diuretic as ordered
D) restrict fluids immediately
Correct Answer: Provide privacy and pour warm water over the perineum
Rationale: Non-invasive measures to stimulate voiding, such as privacy, running water, and warmth,
should be attempted before catheterization. Diuretics are not indicated for postoperative retention
without an order. Fluids may be encouraged, not restricted.
& Verified Answers | 2026 Edition
1. Which of the following best describes the primary purpose of surgical hand antisepsis?
A) To sterilize the hands and forearms completely
B) To reduce the resident microbial flora to a minimum and eliminate transient flora
C) To remove all visible soil from the hands
D) To moisturize the skin before gloving
Correct Answer: To reduce the resident microbial flora to a minimum and eliminate transient flora
Rationale: Surgical hand antisepsis uses antimicrobial agents and prolonged scrubbing to decrease both
transient and resident microorganisms on the skin. Complete sterilization of living skin is not achievable.
Removing visible soil is for routine handwashing, and moisturizing is a skin care, not antiseptic, function.
2. The nurse is preparing a patient for surgery and notes that the informed consent form is signed but
the patient does not understand the risks of the procedure. The nurse should
A) proceed with preoperative preparation
B) notify the surgeon and document the patient's lack of understanding
C) explain the risks again and have the patient sign a new form
D) cancel the surgery without notifying the surgeon
Correct Answer: Notify the surgeon and document the patient's lack of understanding
Rationale: The surgeon performing the procedure is responsible for obtaining informed consent. If the
patient does not understand risks, the nurse must notify the surgeon, who must clarify before the
patient can give valid consent. The nurse can witness but not obtain consent.
3. The nurse is caring for a patient who received preoperative sedation. The patient is now drowsy but
arousable. The nurse should
A) allow the patient to ambulate to the bathroom
,B) raise all four side rails for maximum safety
C) maintain the bed in the lowest position and keep side rails raised per policy
D) place the patient in a semi-Fowler's position without side rails
Correct Answer: Maintain the bed in the lowest position and keep side rails raised per policy
Rationale: A sedated patient is a fall risk. The bed should be in the lowest position, with side rails raised
according to facility policy (usually two or three). Raising all four rails may constitute a restraint.
Ambulation is unsafe until sedation resolves.
4. During the intraoperative phase, the nurse identifies that a patient's position on the operating table
places the patient at risk for injury to the brachial plexus. Which position is most associated with this
risk?
A) Supine with arms padded at the sides
B) Trendelenburg with shoulder braces
C) Lithotomy with legs in stirrups
D) Prone with chest rolls
Correct Answer: Trendelenburg with shoulder braces
Rationale: Shoulder braces used in Trendelenburg position can compress the brachial plexus if placed
incorrectly, causing nerve injury. Supine with padded arms, lithotomy, and prone with chest rolls have
different risk profiles but brachial plexus injury is classic with shoulder braces.
5. The postanesthesia care unit (PACU) nurse is assessing a patient who has just undergone general
anesthesia. Which assessment finding requires immediate intervention?
A) Respiratory rate of 12 breaths per minute
B) Oxygen saturation of 92% on room air
C) Stridor and intercostal retractions
D) Temperature of 96.8°F (36°C)
, Correct Answer: Stridor and intercostal retractions
Rationale: Stridor and retractions indicate upper airway obstruction or laryngeal edema, a life-
threatening complication. Immediate intervention is needed to secure the airway. A rate of 12,
saturation 92% (which may need oxygen), and mild hypothermia are less urgent.
6. The nurse is monitoring a patient in the PACU who suddenly develops a drop in oxygen saturation to
85% and has gurgling respirations. The first action is to
A) administer naloxone
B) call a code blue
C) suction the airway and reposition the head
D) increase IV fluids
Correct Answer: Suction the airway and reposition the head
Rationale: Gurgling indicates secretions in the airway. Suctioning and repositioning (chin lift, jaw thrust)
may rapidly resolve the obstruction. Naloxone is for respiratory depression from opioids. Increasing
fluids does not address airway obstruction.
7. The nurse is caring for a postoperative patient who has not voided in 8 hours after surgery. The
bladder is distended. The first nursing action is to
A) insert an indwelling catheter
B) provide privacy and pour warm water over the perineum
C) administer a diuretic as ordered
D) restrict fluids immediately
Correct Answer: Provide privacy and pour warm water over the perineum
Rationale: Non-invasive measures to stimulate voiding, such as privacy, running water, and warmth,
should be attempted before catheterization. Diuretics are not indicated for postoperative retention
without an order. Fluids may be encouraged, not restricted.
