NURS 120 | NURS120 Exam 4: Introduction to
Medical Surgical Nursing - WCU Updated and
Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a patient who just returned from a total hip arthroplasty. Which
intervention is the priority for preventing prosthesis dislocation?
A. Keep the affected leg adducted at all times.
B. Encourage the patient to cross their legs while sitting.
C. Place an abduction pillow between the patient’s legs.
D. Maintain the hip in at least 110 degrees of flexion.
Correct Answer: C
Expert Explanation: Maintaining hip abduction is critical to keeping the femoral head
within the acetabulum during the initial postoperative healing phase. Adduction or
crossing the legs significantly increases the risk of the prosthesis popping out of the socket.
Flexion beyond 90 degrees is contraindicated as it places undue stress on the surgical site
and can cause dislocation. The abduction pillow provides a physical reminder and
structural support to keep the legs separated. Nurses must consistently assess the patient’s
positioning to ensure the integrity of the new joint.
2. A patient with a lower leg fracture reports a deep, throbbing pain that is unrelieved by the
prescribed morphine. What should the nurse assess for first?
A. Signs of fat embolism syndrome
B. Development of compartment syndrome
C. Presence of a pulmonary embolism
D. Symptoms of osteomyelitis
Correct Answer: B
Expert Explanation: Pain that is out of proportion to the injury and unrelieved by opioids
is a classic early sign of compartment syndrome. This condition occurs when increased
pressure within a muscle compartment compromises circulation and tissue function.
Assessing for the ‘6 Ps’ including pallor, pulselessness, and paresthesia is essential but pain
is the most reliable early indicator. Fat embolism typically presents with respiratory
distress and petechiae, which are different from localized throbbing pain. Prompt
recognition is vital to prevent permanent nerve damage or limb loss.
,3. The nurse is monitoring a patient with a traumatic brain injury. Which clinical
manifestation is the earliest indicator of increased intracranial pressure (ICP)?
A. Change in the level of consciousness
B. Cushing’s triad (bradycardia, hypertension, bradypnea)
C. Fixed and dilated pupils
D. Decorticate posturing
Correct Answer: A
Expert Explanation: A change in the level of consciousness, such as restlessness or
agitation, is the most sensitive and earliest sign of rising ICP. Cushing’s triad is considered a
late sign and indicates that the brain is beginning to herniate. Pupillary changes and
posturing also occur later as the pressure affects specific brain structures like the
oculomotor nerve. Monitoring the Glasgow Coma Scale (GCS) allows nurses to detect these
subtle changes before permanent damage occurs. Early intervention can prevent the
progression to more severe neurological deficits.
4. A patient with a T6 spinal cord injury reports a sudden severe headache and has a blood
pressure of 190/100 mmHg. What is the nurse’s immediate action?
A. Administer an antihypertensive medication immediately.
B. Sit the patient upright and check for bladder distension.
C. Place the patient in a supine position to rest.
D. Call the physician before performing any assessment.
Correct Answer: B
Expert Explanation: These symptoms indicate autonomic dysreflexia, a medical
emergency common in patients with spinal cord injuries above T6. Sitting the patient
upright helps use gravity to lower blood pressure slightly while investigating the cause.
The most common triggers are a full bladder or impacted bowel, so checking for catheter
kinks or distension is a priority. Administering meds before removing the noxious stimulus
is incorrect as the BP will usually drop once the trigger is removed. Placing the patient
supine would dangerously increase intracranial pressure further.
5. Which task is most appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP) for a patient recovering from a stroke?
A. Evaluating the patient’s ability to swallow thick liquids
B. Performing passive range-of-motion exercises on the affected side
C. Teaching the patient how to use a quad cane
D. Assessing the patient’s neurological status using the GCS
, Correct Answer: B
Expert Explanation: Delegation to UAPs should involve tasks that are repetitive, non-
invasive, and do not require clinical judgment. Performing range-of-motion exercises falls
under standard care that UAPs can be trained to perform safely. Evaluating swallowing,
teaching use of assistive devices, and performing neurological assessments all require the
specialized knowledge and judgment of a registered nurse. The nurse remains responsible
for ensuring the UAP performs the task correctly and safely. Clear communication about
the patient’s specific limitations on the affected side is essential before delegation.
6. A patient is admitted with a suspected ischemic stroke. Which diagnostic test is the priority
to rule out a hemorrhagic stroke before starting fibrinolytic therapy?
A. Computed tomography (CT) scan without contrast
B. Magnetic resonance imaging (MRI)
C. Electroencephalogram (EEG)
D. Lumbar puncture
Correct Answer: A
Expert Explanation: A non-contrast CT scan is the gold standard for rapidly differentiating
between ischemic and hemorrhagic strokes. It is essential to exclude hemorrhage before
administering thrombolytics like tPA, as these drugs would worsen a bleed. While an MRI is
more detailed, it takes significantly longer to perform and is not always available in
emergency settings. An EEG measures electrical activity and is not used to visualize brain
structure or bleeding. Speed is critical in stroke care to preserve brain tissue, making the
CT the priority.
7. The nurse is caring for a patient in Buck’s skin traction. Which nursing action is essential for
maintaining effective traction?
A. Allowing the weights to rest on the floor when the patient sleeps.
B. Removing the weights for 10 minutes every hour for skin care.
C. Ensuring the weights hang freely and do not touch the floor.
D. Lifting the weights manually when repositioning the patient.
Correct Answer: C
Expert Explanation: For traction to be effective, the weights must hang freely at all times
to maintain a continuous pulling force. If the weights touch the floor or the bed, the
therapeutic tension is lost and the bone alignment is compromised. Weights should never
be removed without a specific physician’s order, especially for skin care or repositioning.
Lifting the weights manually interrupts the traction and can cause muscle spasms or
further injury. Proper maintenance of the traction system is a key nursing responsibility in
musculoskeletal care.
Medical Surgical Nursing - WCU Updated and
Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a patient who just returned from a total hip arthroplasty. Which
intervention is the priority for preventing prosthesis dislocation?
A. Keep the affected leg adducted at all times.
B. Encourage the patient to cross their legs while sitting.
C. Place an abduction pillow between the patient’s legs.
D. Maintain the hip in at least 110 degrees of flexion.
Correct Answer: C
Expert Explanation: Maintaining hip abduction is critical to keeping the femoral head
within the acetabulum during the initial postoperative healing phase. Adduction or
crossing the legs significantly increases the risk of the prosthesis popping out of the socket.
Flexion beyond 90 degrees is contraindicated as it places undue stress on the surgical site
and can cause dislocation. The abduction pillow provides a physical reminder and
structural support to keep the legs separated. Nurses must consistently assess the patient’s
positioning to ensure the integrity of the new joint.
2. A patient with a lower leg fracture reports a deep, throbbing pain that is unrelieved by the
prescribed morphine. What should the nurse assess for first?
A. Signs of fat embolism syndrome
B. Development of compartment syndrome
C. Presence of a pulmonary embolism
D. Symptoms of osteomyelitis
Correct Answer: B
Expert Explanation: Pain that is out of proportion to the injury and unrelieved by opioids
is a classic early sign of compartment syndrome. This condition occurs when increased
pressure within a muscle compartment compromises circulation and tissue function.
Assessing for the ‘6 Ps’ including pallor, pulselessness, and paresthesia is essential but pain
is the most reliable early indicator. Fat embolism typically presents with respiratory
distress and petechiae, which are different from localized throbbing pain. Prompt
recognition is vital to prevent permanent nerve damage or limb loss.
,3. The nurse is monitoring a patient with a traumatic brain injury. Which clinical
manifestation is the earliest indicator of increased intracranial pressure (ICP)?
A. Change in the level of consciousness
B. Cushing’s triad (bradycardia, hypertension, bradypnea)
C. Fixed and dilated pupils
D. Decorticate posturing
Correct Answer: A
Expert Explanation: A change in the level of consciousness, such as restlessness or
agitation, is the most sensitive and earliest sign of rising ICP. Cushing’s triad is considered a
late sign and indicates that the brain is beginning to herniate. Pupillary changes and
posturing also occur later as the pressure affects specific brain structures like the
oculomotor nerve. Monitoring the Glasgow Coma Scale (GCS) allows nurses to detect these
subtle changes before permanent damage occurs. Early intervention can prevent the
progression to more severe neurological deficits.
4. A patient with a T6 spinal cord injury reports a sudden severe headache and has a blood
pressure of 190/100 mmHg. What is the nurse’s immediate action?
A. Administer an antihypertensive medication immediately.
B. Sit the patient upright and check for bladder distension.
C. Place the patient in a supine position to rest.
D. Call the physician before performing any assessment.
Correct Answer: B
Expert Explanation: These symptoms indicate autonomic dysreflexia, a medical
emergency common in patients with spinal cord injuries above T6. Sitting the patient
upright helps use gravity to lower blood pressure slightly while investigating the cause.
The most common triggers are a full bladder or impacted bowel, so checking for catheter
kinks or distension is a priority. Administering meds before removing the noxious stimulus
is incorrect as the BP will usually drop once the trigger is removed. Placing the patient
supine would dangerously increase intracranial pressure further.
5. Which task is most appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP) for a patient recovering from a stroke?
A. Evaluating the patient’s ability to swallow thick liquids
B. Performing passive range-of-motion exercises on the affected side
C. Teaching the patient how to use a quad cane
D. Assessing the patient’s neurological status using the GCS
, Correct Answer: B
Expert Explanation: Delegation to UAPs should involve tasks that are repetitive, non-
invasive, and do not require clinical judgment. Performing range-of-motion exercises falls
under standard care that UAPs can be trained to perform safely. Evaluating swallowing,
teaching use of assistive devices, and performing neurological assessments all require the
specialized knowledge and judgment of a registered nurse. The nurse remains responsible
for ensuring the UAP performs the task correctly and safely. Clear communication about
the patient’s specific limitations on the affected side is essential before delegation.
6. A patient is admitted with a suspected ischemic stroke. Which diagnostic test is the priority
to rule out a hemorrhagic stroke before starting fibrinolytic therapy?
A. Computed tomography (CT) scan without contrast
B. Magnetic resonance imaging (MRI)
C. Electroencephalogram (EEG)
D. Lumbar puncture
Correct Answer: A
Expert Explanation: A non-contrast CT scan is the gold standard for rapidly differentiating
between ischemic and hemorrhagic strokes. It is essential to exclude hemorrhage before
administering thrombolytics like tPA, as these drugs would worsen a bleed. While an MRI is
more detailed, it takes significantly longer to perform and is not always available in
emergency settings. An EEG measures electrical activity and is not used to visualize brain
structure or bleeding. Speed is critical in stroke care to preserve brain tissue, making the
CT the priority.
7. The nurse is caring for a patient in Buck’s skin traction. Which nursing action is essential for
maintaining effective traction?
A. Allowing the weights to rest on the floor when the patient sleeps.
B. Removing the weights for 10 minutes every hour for skin care.
C. Ensuring the weights hang freely and do not touch the floor.
D. Lifting the weights manually when repositioning the patient.
Correct Answer: C
Expert Explanation: For traction to be effective, the weights must hang freely at all times
to maintain a continuous pulling force. If the weights touch the floor or the bed, the
therapeutic tension is lost and the bone alignment is compromised. Weights should never
be removed without a specific physician’s order, especially for skin care or repositioning.
Lifting the weights manually interrupts the traction and can cause muscle spasms or
further injury. Proper maintenance of the traction system is a key nursing responsibility in
musculoskeletal care.
