NURS 120 | NURS120 Exam 4: Med Surg 1 - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is preparing a patient for surgery. Who is ultimately responsible for obtaining the
patient’s informed consent?
A. The surgeon
B. The surgical technician
C. The registered nurse
D. The anesthesiologist
Correct Answer: A
Rationale: The surgeon is legally responsible for providing the necessary information
about the procedure to the patient. This includes discussing the risks, benefits, and
alternatives of the surgery. The nurse’s role is limited to witnessing the patient’s signature
on the consent form. If the patient expresses a lack of understanding, the nurse must notify
the surgeon immediately. This ensures that the patient’s right to self-determination and
informed choice is maintained throughout the perioperative process.
2. The Glasgow Coma Scale (GCS) measures which three main categories of neurological
function?
A. Pupillary response, motor response, and verbal response
B. Eye opening, verbal response, and motor response
C. Heart rate, respiratory rate, and blood pressure
D. Orientation, memory, and cognitive processing
Correct Answer: B
Rationale: The Glasgow Coma Scale is a standardized tool used to assess a patient’s level of
consciousness. It evaluates three specific areas: eye opening, verbal response, and motor
response. Each area is assigned a numerical score, with a total score ranging from 3 to 15. A
score of 8 or less is generally indicative of a severe brain injury or coma. Consistent use of
the GCS allows for objective tracking of neurological changes over time in acute care
settings.
3. A patient is 12 hours post-operative following a total hip arthroplasty. Which position
should the nurse maintain for the affected extremity?
A. Adduction with internal rotation
B. Flexion of the hip greater than 90 degrees
,C. Abduction with a wedge pillow
D. Extreme external rotation
Correct Answer: C
Rationale: Following a total hip arthroplasty, preventing dislocation of the new prosthesis
is a critical nursing priority. The nurse must use an abduction pillow or wedge to keep the
legs apart and prevent adduction. The patient should also be instructed to avoid crossing
their legs or bending the hip beyond 90 degrees. These precautions are typically
maintained for several weeks post-surgery to allow the joint capsule to heal. Proper
positioning reduces the risk of the femoral head slipping out of the acetabular component.
4. During the pre-operative phase, the nurse administers Atropine as a premedication. What
is the primary rationale for this drug?
A. To induce sedation and reduce anxiety
B. To reduce oral and respiratory secretions
C. To prevent post-operative nausea and vomiting
D. To lower the patient’s blood pressure
Correct Answer: B
Rationale: Atropine is an anticholinergic medication often used before surgery to decrease
the production of saliva and respiratory tract secretions. This helps to prevent aspiration
and maintain a clear airway during the induction of anesthesia and intubation. It also has
the effect of increasing the heart rate, which can counteract bradycardia caused by certain
anesthetic agents. While it may slightly sedate, that is not its primary intended use in this
context. Monitoring for side effects like dry mouth and tachycardia is part of pre-operative
nursing care.
5. Which clinical finding is considered an early sign of increased intracranial pressure (ICP)?
A. Cushing’s triad
B. Dilated and fixed pupils
C. Decerebrate posturing
D. Altered level of consciousness
Correct Answer: D
Rationale: An altered level of consciousness (LOC) is the most sensitive and earliest
indicator of rising intracranial pressure. As pressure increases, cerebral perfusion is
compromised, affecting brain cell function and cognitive awareness. Patients may show
subtle signs such as restlessness, confusion, or irritability before more physical symptoms
appear. Cushing’s triad and fixed pupils are late signs that indicate impending brain
, herniation. Early detection and intervention are vital to prevent irreversible neurological
damage.
6. A patient with a lower leg fracture is complaining of severe pain that is not relieved by
morphine. The nurse notes the toes are pale and the pulse is weak. What should the nurse
suspect?
A. Deep vein thrombosis (DVT)
B. Compartment syndrome
C. Fat embolism syndrome
D. Osteomyelitis
Correct Answer: B
Rationale: Compartment syndrome occurs when increased pressure within a muscle
compartment compromises circulation and tissue function. The hallmark sign is pain that is
out of proportion to the injury and unresponsive to opioid analgesics. Other signs include
paresthesia, pallor, pulselessness, and paralysis of the affected limb. This is a surgical
emergency that often requires a fasciotomy to relieve the internal pressure. Delay in
treatment can lead to permanent muscle loss and nerve damage.
7. A patient undergoes general anesthesia and develops muscle rigidity, a rapidly rising
temperature, and tachycardia. Which medication should the nurse expect to administer?
A. Epinephrine
B. Dantrolene sodium
C. Naloxone
D. Atropine
Correct Answer: B
Rationale: These symptoms are characteristic of Malignant Hyperthermia (MH), a rare but
life-threatening reaction to certain anesthetic gases and muscle relaxants. Dantrolene
sodium is the specific antidote that works by slowing the release of calcium into muscle
cells. Along with medication, the surgical team must immediately stop the triggering agents
and cool the patient. Tachycardia and high fever are metabolic consequences of the
hypermetabolic state triggered by the disorder. Rapid intervention is essential to prevent
cardiovascular collapse and organ failure.
8. What is the recommended timeframe for administering tissue plasminogen activator (tPA)
to a patient experiencing an ischemic stroke?
A. Within 24 hours of symptom onset
B. Within 3 to 4.5 hours of symptom onset
C. Only after 12 hours have passed to confirm the stroke
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is preparing a patient for surgery. Who is ultimately responsible for obtaining the
patient’s informed consent?
A. The surgeon
B. The surgical technician
C. The registered nurse
D. The anesthesiologist
Correct Answer: A
Rationale: The surgeon is legally responsible for providing the necessary information
about the procedure to the patient. This includes discussing the risks, benefits, and
alternatives of the surgery. The nurse’s role is limited to witnessing the patient’s signature
on the consent form. If the patient expresses a lack of understanding, the nurse must notify
the surgeon immediately. This ensures that the patient’s right to self-determination and
informed choice is maintained throughout the perioperative process.
2. The Glasgow Coma Scale (GCS) measures which three main categories of neurological
function?
A. Pupillary response, motor response, and verbal response
B. Eye opening, verbal response, and motor response
C. Heart rate, respiratory rate, and blood pressure
D. Orientation, memory, and cognitive processing
Correct Answer: B
Rationale: The Glasgow Coma Scale is a standardized tool used to assess a patient’s level of
consciousness. It evaluates three specific areas: eye opening, verbal response, and motor
response. Each area is assigned a numerical score, with a total score ranging from 3 to 15. A
score of 8 or less is generally indicative of a severe brain injury or coma. Consistent use of
the GCS allows for objective tracking of neurological changes over time in acute care
settings.
3. A patient is 12 hours post-operative following a total hip arthroplasty. Which position
should the nurse maintain for the affected extremity?
A. Adduction with internal rotation
B. Flexion of the hip greater than 90 degrees
,C. Abduction with a wedge pillow
D. Extreme external rotation
Correct Answer: C
Rationale: Following a total hip arthroplasty, preventing dislocation of the new prosthesis
is a critical nursing priority. The nurse must use an abduction pillow or wedge to keep the
legs apart and prevent adduction. The patient should also be instructed to avoid crossing
their legs or bending the hip beyond 90 degrees. These precautions are typically
maintained for several weeks post-surgery to allow the joint capsule to heal. Proper
positioning reduces the risk of the femoral head slipping out of the acetabular component.
4. During the pre-operative phase, the nurse administers Atropine as a premedication. What
is the primary rationale for this drug?
A. To induce sedation and reduce anxiety
B. To reduce oral and respiratory secretions
C. To prevent post-operative nausea and vomiting
D. To lower the patient’s blood pressure
Correct Answer: B
Rationale: Atropine is an anticholinergic medication often used before surgery to decrease
the production of saliva and respiratory tract secretions. This helps to prevent aspiration
and maintain a clear airway during the induction of anesthesia and intubation. It also has
the effect of increasing the heart rate, which can counteract bradycardia caused by certain
anesthetic agents. While it may slightly sedate, that is not its primary intended use in this
context. Monitoring for side effects like dry mouth and tachycardia is part of pre-operative
nursing care.
5. Which clinical finding is considered an early sign of increased intracranial pressure (ICP)?
A. Cushing’s triad
B. Dilated and fixed pupils
C. Decerebrate posturing
D. Altered level of consciousness
Correct Answer: D
Rationale: An altered level of consciousness (LOC) is the most sensitive and earliest
indicator of rising intracranial pressure. As pressure increases, cerebral perfusion is
compromised, affecting brain cell function and cognitive awareness. Patients may show
subtle signs such as restlessness, confusion, or irritability before more physical symptoms
appear. Cushing’s triad and fixed pupils are late signs that indicate impending brain
, herniation. Early detection and intervention are vital to prevent irreversible neurological
damage.
6. A patient with a lower leg fracture is complaining of severe pain that is not relieved by
morphine. The nurse notes the toes are pale and the pulse is weak. What should the nurse
suspect?
A. Deep vein thrombosis (DVT)
B. Compartment syndrome
C. Fat embolism syndrome
D. Osteomyelitis
Correct Answer: B
Rationale: Compartment syndrome occurs when increased pressure within a muscle
compartment compromises circulation and tissue function. The hallmark sign is pain that is
out of proportion to the injury and unresponsive to opioid analgesics. Other signs include
paresthesia, pallor, pulselessness, and paralysis of the affected limb. This is a surgical
emergency that often requires a fasciotomy to relieve the internal pressure. Delay in
treatment can lead to permanent muscle loss and nerve damage.
7. A patient undergoes general anesthesia and develops muscle rigidity, a rapidly rising
temperature, and tachycardia. Which medication should the nurse expect to administer?
A. Epinephrine
B. Dantrolene sodium
C. Naloxone
D. Atropine
Correct Answer: B
Rationale: These symptoms are characteristic of Malignant Hyperthermia (MH), a rare but
life-threatening reaction to certain anesthetic gases and muscle relaxants. Dantrolene
sodium is the specific antidote that works by slowing the release of calcium into muscle
cells. Along with medication, the surgical team must immediately stop the triggering agents
and cool the patient. Tachycardia and high fever are metabolic consequences of the
hypermetabolic state triggered by the disorder. Rapid intervention is essential to prevent
cardiovascular collapse and organ failure.
8. What is the recommended timeframe for administering tissue plasminogen activator (tPA)
to a patient experiencing an ischemic stroke?
A. Within 24 hours of symptom onset
B. Within 3 to 4.5 hours of symptom onset
C. Only after 12 hours have passed to confirm the stroke
