Midterm Exam: NURS201/ NURS 201 (Latest Update) Medical Surgical
Nursing- Promoting Wellness | Qs & As| Grade A| 100% Correct
(Verified Answers)- WCU
Question 1
A nurse is conducting a preoperative assessment on a client scheduled for a cholecystectomy.
The client reports a family history of a sibling dying during surgery due to a sudden high fever.
The nurse should prioritize notifying the anesthesiologist about a potential risk for which
condition?
A) Anaphylaxis
B) Sepsis
C) Malignant hyperthermia
D) Disseminated intravascular coagulation (DIC)
E) Adrenal crisis
Correct Answer: C) Malignant hyperthermia
Rationale: Malignant hyperthermia is a rare, life-threatening inherited muscle disorder
triggered by certain general anesthetics (e.g., succinylcholine, halothane). It causes a
hypermetabolic state with sustained muscle contraction, leading to hyperthermia,
tachycardia, and acidosis. A positive family history is the single most important risk factor,
making it crucial to communicate this information to the anesthesia team to ensure
appropriate precautions are taken and alternative anesthetics are used.
Question 2
A nurse is caring for a client in the post-anesthesia care unit (PACU) who is 1 hour post-
operative. The client's oxygen saturation has dropped from 97% to 89%, and breath sounds are
diminished in the lung bases. Which of the following is the most likely cause of this finding?
A) Pneumothorax
B) Pulmonary embolism
C) Laryngospasm
D) Atelectasis
E) Aspiration pneumonia
,[Type here]
Correct Answer: D) Atelectasis
Rationale: Atelectasis, the collapse of alveoli, is the most common postoperative respiratory
complication. It is caused by shallow breathing, mucous plugs, and the effects of anesthesia.
The resulting blockage prevents air from reaching the alveoli, leading to diminished breath
sounds and impaired gas exchange (hypoxemia), which is reflected in a decreased oxygen
saturation.
Question 3
The nurse is assessing a client's surgical incision 2 days post-operatively and notes a separation
of the wound edges with the protrusion of internal organs. What is the nurse's immediate action?
A) Gently attempt to push the organs back into the abdominal cavity.
B) Place the client in a high-Fowler's position to reduce abdominal pressure.
C) Document the finding and notify the surgeon at the next rounding time.
D) Cover the exposed organs with a sterile saline-soaked dressing.
E) Administer a stat dose of a prescribed oral analgesic for pain.
Correct Answer: D) Cover the exposed organs with a sterile saline-soaked dressing.
Rationale: This finding is wound evisceration, a surgical emergency. The immediate priority
is to protect the exposed organs from contamination and drying out. The nurse should
cover them with a non-adherent dressing soaked in sterile saline. The client should be
placed in a low-Fowler's position with knees bent to minimize abdominal tension, and the
surgeon must be notified immediately.
Question 4
A nurse is preparing a client for surgery. The client states, "I'm not sure if I really want this
surgery. I don't understand what they are going to do." The client has already signed the consent
form. What is the nurse's most appropriate action?
A) Explain the surgical procedure to the client in simple terms.
B) Reassure the client that the surgeon is very skilled and they have nothing to worry about.
C) Notify the surgeon of the client's statement and request they speak with the client.
D) Document that the client expressed doubts but has a signed consent on file.
E) Provide the client with a pamphlet about the surgical procedure.
,[Type here]
Correct Answer: C) Notify the surgeon of the client's statement and request they speak with
the client.
Rationale: Informed consent is a legal and ethical requirement. It is the surgeon's
responsibility to provide a clear explanation of the procedure, its risks, benefits, and
alternatives. If the client expresses doubt or a lack of understanding, the consent is not
considered "informed." The nurse's role is to act as a client advocate and must notify the
surgeon to provide the necessary clarification before the client proceeds to surgery.
Question 5
A client in the PACU has a blood pressure of 90/50 mmHg, a heart rate of 120 bpm, and cool,
clammy skin. The surgical dressing is dry and intact. The nurse suspects the client is
experiencing which type of shock?
A) Cardiogenic shock
B) Neurogenic shock
C) Hypovolemic shock
D) Anaphylactic shock
E) Septic shock
Correct Answer: C) Hypovolemic shock
Rationale: Even with a dry dressing, a client can experience internal bleeding (hemorrhage)
after surgery. The classic signs of hypovolemic shock are hypotension and tachycardia,
which are compensatory mechanisms for decreased circulating blood volume. Cool,
clammy skin results from peripheral vasoconstriction as the body shunts blood to vital
organs. This is the most likely cause in an immediate post-operative client.
Question 6
A nurse is caring for an older adult client with dehydration. Which laboratory finding would the
nurse expect to see?
A) Serum sodium of 130 mEq/L
B) Decreased hematocrit
C) Urine specific gravity of 1.005
D) Increased serum osmolality
E) Serum potassium of 5.5 mEq/L
, [Type here]
Correct Answer: D) Increased serum osmolality
Rationale: Dehydration is a state of fluid volume deficit where water loss exceeds solute loss,
leading to hemoconcentration. This means the blood has a higher concentration of solutes,
which is reflected as an increased serum osmolality (normal is 275-295 mOsm/kg). The
hematocrit would be elevated, and the urine specific gravity would be high (>1.030) as the
kidneys try to conserve water.
Question 7
A client is admitted with fluid volume excess and a history of heart failure. Which assessment
finding is the most reliable indicator of the client's fluid status?
A) Presence of peripheral edema
B) Crackles in the lung bases
C) Daily weight
D) Thirst level
E) Intake and output records
Correct Answer: C) Daily weight
Rationale: Daily weight is the single most sensitive and reliable indicator of fluid status. A
weight change of 1 kg (2.2 lbs) corresponds to a fluid volume change of approximately 1
liter. While edema and crackles are important signs, they can be subjective and may not
appear until significant fluid has accumulated. Daily weight provides an objective,
measurable data point.
Question 8
A client is receiving a 3% sodium chloride intravenous infusion for severe hyponatremia. The
nurse should monitor for which of the following as a potential complication of this therapy?
A) Hypokalemia
B) Pulmonary edema
C) Renal failure
D) Metabolic acidosis
E) Seizures
Correct Answer: B) Pulmonary edema
Rationale: 3% sodium chloride is a hypertonic solution that rapidly pulls fluid from the
Nursing- Promoting Wellness | Qs & As| Grade A| 100% Correct
(Verified Answers)- WCU
Question 1
A nurse is conducting a preoperative assessment on a client scheduled for a cholecystectomy.
The client reports a family history of a sibling dying during surgery due to a sudden high fever.
The nurse should prioritize notifying the anesthesiologist about a potential risk for which
condition?
A) Anaphylaxis
B) Sepsis
C) Malignant hyperthermia
D) Disseminated intravascular coagulation (DIC)
E) Adrenal crisis
Correct Answer: C) Malignant hyperthermia
Rationale: Malignant hyperthermia is a rare, life-threatening inherited muscle disorder
triggered by certain general anesthetics (e.g., succinylcholine, halothane). It causes a
hypermetabolic state with sustained muscle contraction, leading to hyperthermia,
tachycardia, and acidosis. A positive family history is the single most important risk factor,
making it crucial to communicate this information to the anesthesia team to ensure
appropriate precautions are taken and alternative anesthetics are used.
Question 2
A nurse is caring for a client in the post-anesthesia care unit (PACU) who is 1 hour post-
operative. The client's oxygen saturation has dropped from 97% to 89%, and breath sounds are
diminished in the lung bases. Which of the following is the most likely cause of this finding?
A) Pneumothorax
B) Pulmonary embolism
C) Laryngospasm
D) Atelectasis
E) Aspiration pneumonia
,[Type here]
Correct Answer: D) Atelectasis
Rationale: Atelectasis, the collapse of alveoli, is the most common postoperative respiratory
complication. It is caused by shallow breathing, mucous plugs, and the effects of anesthesia.
The resulting blockage prevents air from reaching the alveoli, leading to diminished breath
sounds and impaired gas exchange (hypoxemia), which is reflected in a decreased oxygen
saturation.
Question 3
The nurse is assessing a client's surgical incision 2 days post-operatively and notes a separation
of the wound edges with the protrusion of internal organs. What is the nurse's immediate action?
A) Gently attempt to push the organs back into the abdominal cavity.
B) Place the client in a high-Fowler's position to reduce abdominal pressure.
C) Document the finding and notify the surgeon at the next rounding time.
D) Cover the exposed organs with a sterile saline-soaked dressing.
E) Administer a stat dose of a prescribed oral analgesic for pain.
Correct Answer: D) Cover the exposed organs with a sterile saline-soaked dressing.
Rationale: This finding is wound evisceration, a surgical emergency. The immediate priority
is to protect the exposed organs from contamination and drying out. The nurse should
cover them with a non-adherent dressing soaked in sterile saline. The client should be
placed in a low-Fowler's position with knees bent to minimize abdominal tension, and the
surgeon must be notified immediately.
Question 4
A nurse is preparing a client for surgery. The client states, "I'm not sure if I really want this
surgery. I don't understand what they are going to do." The client has already signed the consent
form. What is the nurse's most appropriate action?
A) Explain the surgical procedure to the client in simple terms.
B) Reassure the client that the surgeon is very skilled and they have nothing to worry about.
C) Notify the surgeon of the client's statement and request they speak with the client.
D) Document that the client expressed doubts but has a signed consent on file.
E) Provide the client with a pamphlet about the surgical procedure.
,[Type here]
Correct Answer: C) Notify the surgeon of the client's statement and request they speak with
the client.
Rationale: Informed consent is a legal and ethical requirement. It is the surgeon's
responsibility to provide a clear explanation of the procedure, its risks, benefits, and
alternatives. If the client expresses doubt or a lack of understanding, the consent is not
considered "informed." The nurse's role is to act as a client advocate and must notify the
surgeon to provide the necessary clarification before the client proceeds to surgery.
Question 5
A client in the PACU has a blood pressure of 90/50 mmHg, a heart rate of 120 bpm, and cool,
clammy skin. The surgical dressing is dry and intact. The nurse suspects the client is
experiencing which type of shock?
A) Cardiogenic shock
B) Neurogenic shock
C) Hypovolemic shock
D) Anaphylactic shock
E) Septic shock
Correct Answer: C) Hypovolemic shock
Rationale: Even with a dry dressing, a client can experience internal bleeding (hemorrhage)
after surgery. The classic signs of hypovolemic shock are hypotension and tachycardia,
which are compensatory mechanisms for decreased circulating blood volume. Cool,
clammy skin results from peripheral vasoconstriction as the body shunts blood to vital
organs. This is the most likely cause in an immediate post-operative client.
Question 6
A nurse is caring for an older adult client with dehydration. Which laboratory finding would the
nurse expect to see?
A) Serum sodium of 130 mEq/L
B) Decreased hematocrit
C) Urine specific gravity of 1.005
D) Increased serum osmolality
E) Serum potassium of 5.5 mEq/L
, [Type here]
Correct Answer: D) Increased serum osmolality
Rationale: Dehydration is a state of fluid volume deficit where water loss exceeds solute loss,
leading to hemoconcentration. This means the blood has a higher concentration of solutes,
which is reflected as an increased serum osmolality (normal is 275-295 mOsm/kg). The
hematocrit would be elevated, and the urine specific gravity would be high (>1.030) as the
kidneys try to conserve water.
Question 7
A client is admitted with fluid volume excess and a history of heart failure. Which assessment
finding is the most reliable indicator of the client's fluid status?
A) Presence of peripheral edema
B) Crackles in the lung bases
C) Daily weight
D) Thirst level
E) Intake and output records
Correct Answer: C) Daily weight
Rationale: Daily weight is the single most sensitive and reliable indicator of fluid status. A
weight change of 1 kg (2.2 lbs) corresponds to a fluid volume change of approximately 1
liter. While edema and crackles are important signs, they can be subjective and may not
appear until significant fluid has accumulated. Daily weight provides an objective,
measurable data point.
Question 8
A client is receiving a 3% sodium chloride intravenous infusion for severe hyponatremia. The
nurse should monitor for which of the following as a potential complication of this therapy?
A) Hypokalemia
B) Pulmonary edema
C) Renal failure
D) Metabolic acidosis
E) Seizures
Correct Answer: B) Pulmonary edema
Rationale: 3% sodium chloride is a hypertonic solution that rapidly pulls fluid from the
