NUR 304 | NUR304 Exam 1: Med Surg - MCPHS
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is preparing to enter the room of a patient diagnosed with pulmonary tuberculosis.
Which personal protective equipment (PPE) is most essential for the nurse to wear?
A. Surgical mask
B. Face shield and goggles
C. Gown and gloves
D. N95 respirator mask
Correct Answer: D
Rationale: Airborne precautions are necessary for tuberculosis to prevent the
transmission of small infectious droplets through the air. A private room with negative
pressure is the standard requirement for these patients to contain the pathogen. The nurse
must wear an N95 respirator mask specifically fitted to ensure a tight seal against airborne
pathogens. Surgical masks are only used for droplet precautions and are insufficient for the
micro-particles of tuberculosis. Closing the door is essential to maintain the negative
pressure environment and protect others in the healthcare facility.
2. The nurse is prioritizing care for four patients. Which patient should the nurse assess first?
A. A patient with a pain level of 8 out of 10 after surgery
B. A patient with a blood pressure of 145/90 mmHg
C. A patient reporting shortness of breath and audible wheezing
D. A patient requesting a PRN medication for nausea
Correct Answer: C
Rationale: The nurse should apply the ABC (Airway, Breathing, Circulation) framework to
prioritize patient care effectively. A patient with shortness of breath and wheezing
indicates a potential respiratory compromise that requires immediate intervention. While
pain and high blood pressure are significant, they are generally less critical than an acute
breathing issue. Nausea is a comfort issue and ranks lower than physiological stability in
priority frameworks like Maslow’s. Rapid assessment of the respiratory system can prevent
further deterioration or respiratory arrest in this patient.
3. When caring for a patient with Clostridioides difficile (C. diff), which hand hygiene method
is mandatory for the nurse after providing care?
A. Alcohol-based hand sanitizer
B. Chlorhexidine scrub
,C. Washing with soap and water
D. Using sterile gloves only
Correct Answer: C
Rationale: C. difficile produces spores that are highly resistant to the alcohol found in most
hand sanitizers. Physical scrubbing with soap and water is the only effective way to
mechanically remove these spores from the skin. The friction generated during
handwashing helps detach the bacteria and rinse them away into the sink. Alcohol-based
rubs may kill other bacteria but leave C. diff spores viable and capable of spreading.
Maintaining contact precautions and proper hand hygiene is vital to prevent hospital-
acquired infections among vulnerable populations.
4. During a physical assessment, the nurse is ready to examine the patient’s abdomen. In
what order should the nurse perform the assessment techniques?
A. Inspection, auscultation, percussion, palpation
B. Auscultation, inspection, percussion, palpation
C. Inspection, palpation, percussion, auscultation
D. Palpation, percussion, auscultation, inspection
Correct Answer: A
Rationale: The correct sequence for abdominal assessment is inspection followed by
auscultation before any physical manipulation occurs. Percussion and palpation can
stimulate peristalsis and alter the frequency or character of bowel sounds. By auscultating
early, the nurse obtains a baseline of the natural activity within the gastrointestinal tract.
Starting with inspection allows the nurse to observe for distension or pulsations without
disturbing the patient. This specific order ensures the most accurate physical data
collection and avoids false clinical findings.
5. A patient is admitted with signs of dehydration. Which clinical finding should the nurse
expect to see during the assessment?
A. Dry mucous membranes
B. Hypertension
C. Increased skin turgor
D. Bradycardia
Correct Answer: A
Rationale: Dry mucous membranes are a hallmark sign of fluid volume deficit as the body
prioritizes water for internal organs. Patients with dehydration typically exhibit
tachycardia rather than bradycardia as the heart compensates for low volume.
Hypotension or orthostatic changes are common because there is less circulating blood
, volume to maintain pressure. Skin turgor would be decreased, resulting in ‘tenting’ where
the skin slowly returns to its original position. Monitoring intake and output is essential for
evaluating the effectiveness of rehydration therapies in these patients.
6. The nurse is preparing to administer an oral medication. Which action is the most
important for ensuring patient safety?
A. Checking the patient’s room number on the door
B. Asking the patient if they are ready for the medication
C. Relying on the patient’s name on the medication tray
D. Verifying the patient using two unique identifiers
Correct Answer: D
Rationale: Safety protocols require the nurse to verify the patient’s identity using at least
two unique identifiers like name and date of birth. Room numbers are not reliable
identifiers because patients may be moved or room assignments can change. This practice
prevents medication errors by ensuring the right drug is delivered to the right person.
Checking the medication administration record (MAR) against the patient’s wristband is a
standard safety double-check. Proper identification is a fundamental component of the ‘Six
Rights’ of medication administration used in nursing.
7. A nurse identifies a localized area of intact skin with non-blanchable redness over the
patient’s sacrum. How should the nurse document this finding?
A. Deep tissue injury
B. Stage II pressure injury
C. Stage I pressure injury
D. Unstageable pressure injury
Correct Answer: C
Rationale: A Stage I pressure injury is characterized by intact skin with localized redness
that does not blanch when pressed. This indicates that the underlying tissue has suffered
from pressure but the skin surface is not yet broken. Stage II injuries involve partial-
thickness loss of skin such as a blister or an open ulcer. Deep tissue injuries usually appear
as purple or maroon discoloration rather than simple redness. Accurate documentation
and early intervention are crucial to prevent the progression of skin breakdown in
immobile patients.
8. A nurse is collecting data during a health history. Which of the following is considered
subjective data?
A. Blood pressure of 110/70 mmHg
B. A patient’s report of a dull headache
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is preparing to enter the room of a patient diagnosed with pulmonary tuberculosis.
Which personal protective equipment (PPE) is most essential for the nurse to wear?
A. Surgical mask
B. Face shield and goggles
C. Gown and gloves
D. N95 respirator mask
Correct Answer: D
Rationale: Airborne precautions are necessary for tuberculosis to prevent the
transmission of small infectious droplets through the air. A private room with negative
pressure is the standard requirement for these patients to contain the pathogen. The nurse
must wear an N95 respirator mask specifically fitted to ensure a tight seal against airborne
pathogens. Surgical masks are only used for droplet precautions and are insufficient for the
micro-particles of tuberculosis. Closing the door is essential to maintain the negative
pressure environment and protect others in the healthcare facility.
2. The nurse is prioritizing care for four patients. Which patient should the nurse assess first?
A. A patient with a pain level of 8 out of 10 after surgery
B. A patient with a blood pressure of 145/90 mmHg
C. A patient reporting shortness of breath and audible wheezing
D. A patient requesting a PRN medication for nausea
Correct Answer: C
Rationale: The nurse should apply the ABC (Airway, Breathing, Circulation) framework to
prioritize patient care effectively. A patient with shortness of breath and wheezing
indicates a potential respiratory compromise that requires immediate intervention. While
pain and high blood pressure are significant, they are generally less critical than an acute
breathing issue. Nausea is a comfort issue and ranks lower than physiological stability in
priority frameworks like Maslow’s. Rapid assessment of the respiratory system can prevent
further deterioration or respiratory arrest in this patient.
3. When caring for a patient with Clostridioides difficile (C. diff), which hand hygiene method
is mandatory for the nurse after providing care?
A. Alcohol-based hand sanitizer
B. Chlorhexidine scrub
,C. Washing with soap and water
D. Using sterile gloves only
Correct Answer: C
Rationale: C. difficile produces spores that are highly resistant to the alcohol found in most
hand sanitizers. Physical scrubbing with soap and water is the only effective way to
mechanically remove these spores from the skin. The friction generated during
handwashing helps detach the bacteria and rinse them away into the sink. Alcohol-based
rubs may kill other bacteria but leave C. diff spores viable and capable of spreading.
Maintaining contact precautions and proper hand hygiene is vital to prevent hospital-
acquired infections among vulnerable populations.
4. During a physical assessment, the nurse is ready to examine the patient’s abdomen. In
what order should the nurse perform the assessment techniques?
A. Inspection, auscultation, percussion, palpation
B. Auscultation, inspection, percussion, palpation
C. Inspection, palpation, percussion, auscultation
D. Palpation, percussion, auscultation, inspection
Correct Answer: A
Rationale: The correct sequence for abdominal assessment is inspection followed by
auscultation before any physical manipulation occurs. Percussion and palpation can
stimulate peristalsis and alter the frequency or character of bowel sounds. By auscultating
early, the nurse obtains a baseline of the natural activity within the gastrointestinal tract.
Starting with inspection allows the nurse to observe for distension or pulsations without
disturbing the patient. This specific order ensures the most accurate physical data
collection and avoids false clinical findings.
5. A patient is admitted with signs of dehydration. Which clinical finding should the nurse
expect to see during the assessment?
A. Dry mucous membranes
B. Hypertension
C. Increased skin turgor
D. Bradycardia
Correct Answer: A
Rationale: Dry mucous membranes are a hallmark sign of fluid volume deficit as the body
prioritizes water for internal organs. Patients with dehydration typically exhibit
tachycardia rather than bradycardia as the heart compensates for low volume.
Hypotension or orthostatic changes are common because there is less circulating blood
, volume to maintain pressure. Skin turgor would be decreased, resulting in ‘tenting’ where
the skin slowly returns to its original position. Monitoring intake and output is essential for
evaluating the effectiveness of rehydration therapies in these patients.
6. The nurse is preparing to administer an oral medication. Which action is the most
important for ensuring patient safety?
A. Checking the patient’s room number on the door
B. Asking the patient if they are ready for the medication
C. Relying on the patient’s name on the medication tray
D. Verifying the patient using two unique identifiers
Correct Answer: D
Rationale: Safety protocols require the nurse to verify the patient’s identity using at least
two unique identifiers like name and date of birth. Room numbers are not reliable
identifiers because patients may be moved or room assignments can change. This practice
prevents medication errors by ensuring the right drug is delivered to the right person.
Checking the medication administration record (MAR) against the patient’s wristband is a
standard safety double-check. Proper identification is a fundamental component of the ‘Six
Rights’ of medication administration used in nursing.
7. A nurse identifies a localized area of intact skin with non-blanchable redness over the
patient’s sacrum. How should the nurse document this finding?
A. Deep tissue injury
B. Stage II pressure injury
C. Stage I pressure injury
D. Unstageable pressure injury
Correct Answer: C
Rationale: A Stage I pressure injury is characterized by intact skin with localized redness
that does not blanch when pressed. This indicates that the underlying tissue has suffered
from pressure but the skin surface is not yet broken. Stage II injuries involve partial-
thickness loss of skin such as a blister or an open ulcer. Deep tissue injuries usually appear
as purple or maroon discoloration rather than simple redness. Accurate documentation
and early intervention are crucial to prevent the progression of skin breakdown in
immobile patients.
8. A nurse is collecting data during a health history. Which of the following is considered
subjective data?
A. Blood pressure of 110/70 mmHg
B. A patient’s report of a dull headache
