NUR201 Medical Surgical Exam 1 Version 2
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is witnessing a client sign an informed consent form for surgery. Which of
the following is the nurse’s primary responsibility?
A. Explain the risks and benefits of the procedure.
B. Detail the alternative treatments available to the client.
C. Verify the client is competent to provide consent.
D. Perform the preoperative physical assessment.
Correct Answer: C
Expert Explanation: The nurse acts as a witness to ensure the signature is
authentic and the client is competent. It is the surgeon’s legal responsibility to
explain the risks, benefits, and alternatives of the surgery. The nurse must verify
that the client has received this information and understands it before signing. If the
client lacks understanding, the nurse must notify the surgeon to provide further
explanation. This process protects both the client’s rights and the surgical team’s
legal standing.
2. Which clinical manifestation is considered the earliest sign of malignant
hyperthermia in a client receiving general anesthesia?
A. Body temperature of 104°F (40°C)
,B. Muscle rigidity in the jaw
C. Tachycardia
D. Cyanosis
Correct Answer: C
Expert Explanation: Tachycardia is typically the first sign recognized in the
operating room during a malignant hyperthermia crisis. Muscle rigidity, particularly
in the masseter muscle, is another significant early indicator of the condition.
Elevated end-tidal carbon dioxide levels are also measured as an early metabolic
change. Hyperthermia or a high fever is actually a late clinical sign of this life-
threatening syndrome. Prompt recognition allows for the immediate administration
of dantrolene to reverse the process.
3. A client has just arrived in the PACU following abdominal surgery. Which
assessment should the nurse perform first?
A. Check the surgical dressing for drainage.
B. Monitor the client’s urine output.
C. Assess the patency of the airway.
D. Evaluate the client’s pain level.
Correct Answer: C
,Expert Explanation: Airway patency is always the highest priority according to the
ABC (Airway, Breathing, Circulation) framework. Clients recovering from anesthesia
are at high risk for respiratory depression or airway obstruction. The nurse must
ensure the client is ventilating adequately before moving to other assessments. Once
the airway is secure, the nurse can evaluate circulatory status and surgical site
integrity. This sequence of care is essential for maintaining safety during the
immediate postoperative period.
4. The nurse provides preoperative teaching about incentive spirometry. Which
statement by the client indicates understanding?
A. I should blow hard into the device to clear my lungs.
B. I will use this tool once every 8 hours while awake.
C. I need to take a slow, deep breath in to raise the ball.
D. This device will help prevent my surgical wound from opening.
Correct Answer: C
Expert Explanation: Incentive spirometry requires the client to perform a
sustained maximal inspiration to expand the alveoli. This technique helps prevent
atelectasis and pneumonia in the postoperative phase. The client should be
instructed to use the device approximately 10 times every hour while awake.
Exhaling into the device is a common error and does not achieve the therapeutic
, goal. Deep breathing exercises are critical for promoting effective gas exchange after
general anesthesia.
5. A postoperative client is at risk for deep vein thrombosis (DVT). Which intervention
is most effective for prevention?
A. Massaging the calves every 4 hours.
B. Applying sequential compression devices (SCDs).
C. Placing a pillow under the knees while in bed.
D. Restricting oral fluid intake to reduce edema.
Correct Answer: B
Expert Explanation: SCDs promote venous return by applying intermittent
pressure to the lower extremities. This mechanical intervention is a standard of care
for preventing blood clots in immobile surgical patients. Massaging the calves is
strictly contraindicated because it could dislodge an existing clot. Placing pillows
under the knees should be avoided as it can compress veins and impede blood flow.
Early ambulation is also a key strategy used in conjunction with these mechanical
devices.
6. A nurse discovers a client’s surgical wound has eviscerated. What is the immediate
priority action?
A. Push the organs back into the abdominal cavity.
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is witnessing a client sign an informed consent form for surgery. Which of
the following is the nurse’s primary responsibility?
A. Explain the risks and benefits of the procedure.
B. Detail the alternative treatments available to the client.
C. Verify the client is competent to provide consent.
D. Perform the preoperative physical assessment.
Correct Answer: C
Expert Explanation: The nurse acts as a witness to ensure the signature is
authentic and the client is competent. It is the surgeon’s legal responsibility to
explain the risks, benefits, and alternatives of the surgery. The nurse must verify
that the client has received this information and understands it before signing. If the
client lacks understanding, the nurse must notify the surgeon to provide further
explanation. This process protects both the client’s rights and the surgical team’s
legal standing.
2. Which clinical manifestation is considered the earliest sign of malignant
hyperthermia in a client receiving general anesthesia?
A. Body temperature of 104°F (40°C)
,B. Muscle rigidity in the jaw
C. Tachycardia
D. Cyanosis
Correct Answer: C
Expert Explanation: Tachycardia is typically the first sign recognized in the
operating room during a malignant hyperthermia crisis. Muscle rigidity, particularly
in the masseter muscle, is another significant early indicator of the condition.
Elevated end-tidal carbon dioxide levels are also measured as an early metabolic
change. Hyperthermia or a high fever is actually a late clinical sign of this life-
threatening syndrome. Prompt recognition allows for the immediate administration
of dantrolene to reverse the process.
3. A client has just arrived in the PACU following abdominal surgery. Which
assessment should the nurse perform first?
A. Check the surgical dressing for drainage.
B. Monitor the client’s urine output.
C. Assess the patency of the airway.
D. Evaluate the client’s pain level.
Correct Answer: C
,Expert Explanation: Airway patency is always the highest priority according to the
ABC (Airway, Breathing, Circulation) framework. Clients recovering from anesthesia
are at high risk for respiratory depression or airway obstruction. The nurse must
ensure the client is ventilating adequately before moving to other assessments. Once
the airway is secure, the nurse can evaluate circulatory status and surgical site
integrity. This sequence of care is essential for maintaining safety during the
immediate postoperative period.
4. The nurse provides preoperative teaching about incentive spirometry. Which
statement by the client indicates understanding?
A. I should blow hard into the device to clear my lungs.
B. I will use this tool once every 8 hours while awake.
C. I need to take a slow, deep breath in to raise the ball.
D. This device will help prevent my surgical wound from opening.
Correct Answer: C
Expert Explanation: Incentive spirometry requires the client to perform a
sustained maximal inspiration to expand the alveoli. This technique helps prevent
atelectasis and pneumonia in the postoperative phase. The client should be
instructed to use the device approximately 10 times every hour while awake.
Exhaling into the device is a common error and does not achieve the therapeutic
, goal. Deep breathing exercises are critical for promoting effective gas exchange after
general anesthesia.
5. A postoperative client is at risk for deep vein thrombosis (DVT). Which intervention
is most effective for prevention?
A. Massaging the calves every 4 hours.
B. Applying sequential compression devices (SCDs).
C. Placing a pillow under the knees while in bed.
D. Restricting oral fluid intake to reduce edema.
Correct Answer: B
Expert Explanation: SCDs promote venous return by applying intermittent
pressure to the lower extremities. This mechanical intervention is a standard of care
for preventing blood clots in immobile surgical patients. Massaging the calves is
strictly contraindicated because it could dislodge an existing clot. Placing pillows
under the knees should be avoided as it can compress veins and impede blood flow.
Early ambulation is also a key strategy used in conjunction with these mechanical
devices.
6. A nurse discovers a client’s surgical wound has eviscerated. What is the immediate
priority action?
A. Push the organs back into the abdominal cavity.
