NR-324 – Adult Health I | Complete Medical-
Surgical Nursing Study Guide, Adult Patient
Care, Disease Management, Clinical Practice,
and Comprehensive Exam Review
1. A nurse is caring for a postoperative patient who is 6 hours post- abdominal
surgery. The patient reports sudden onset of severe chest pain and shortness
of breath. The nurse auscultates diminished breath sounds on the right side.
Which action should the nurse take first?
A. Administer prescribed PRN morphine.
B. Encourage deep breathing and coughing.
C. Notify the healthcare provider immediately.
D. Apply supplemental oxygen at 2 L/min via nasal cannula.
Rationale: The patient is exhibiting signs of a potential pulmonary embolism
(PE) or pneumothorax, both of which are life-threatening postoperative
complications. While applying oxygen is appropriate, the priority is to notify the
healthcare provider immediately for rapid evaluation and intervention. Sudden
chest pain, dyspnea, and diminished breath sounds are red flags that require
immediate medical attention.
2. A patient is 2 days post-total hip replacement. The nurse notes that the
patient's left calf is swollen, warm, and tender to palpation. Which nursing
action is most appropriate?
A. Apply a heating pad to the calf.
B. Massage the calf to improve circulation.
C. Measure the calf circumference and compare to the right leg.
D. Encourage the patient to ambulate in the hallway.
Rationale: The patient is exhibiting signs of a deep vein thrombosis (DVT) , a
serious postoperative complication. The nurse should measure the calf
circumference and compare it to the unaffected leg to assess for
asymmetry. Massage and heat are contraindicated as they can dislodge a
thrombus. Ambulation should be restricted until a DVT is ruled out.
3. A patient is scheduled for surgery and is NPO. The nurse notes that the
patient has a bedside glass of water. What is the nurse's priority action?
,A. Ignore the water since the patient is not drinking it.
B. Remove the water and remind the patient of NPO status.
C. Allow the patient to drink the water since surgery is hours away.
D. Document that the patient has water at the bedside.
Rationale: The priority is to remove the water and reinforce NPO (nothing by
mouth) teaching to prevent aspiration during surgery. The patient may forget they
are NPO and drink the water, which could lead to surgical cancellation or serious
complications.
4. A postoperative patient's vital signs are: BP 90/60 mmHg, HR 120 bpm, RR
24/min, temperature 38.5°C (101.3°F). The patient's surgical dressing is
saturated with bright red blood. Which nursing action should the nurse
perform first?
A. Administer antipyretics for the fever.
B. Apply pressure to the surgical site.
C. Increase the IV fluid rate.
D. Notify the surgeon.
Rationale: The patient is showing signs of hemorrhage (tachycardia,
hypotension, and bright red blood on the dressing). The immediate priority is
to apply direct pressure to the surgical site to control bleeding. While notifying
the surgeon and increasing fluids are important, they come after immediate
hemorrhage control.
5. A patient who had a cholecystectomy 24 hours ago has an order for early
ambulation. The patient refuses to get out of bed, stating, "It hurts too much."
Which nursing action is most appropriate?
A. Document the refusal and allow the patient to rest.
B. Assess the patient's pain level and administer prescribed analgesia before
ambulation.
C. Tell the patient that ambulation is mandatory.
D. Call the healthcare provider to cancel the order.
Rationale: Early ambulation is crucial postoperatively to prevent complications
such as DVT, pneumonia, and ileus. The nurse should assess the patient's pain
and administer analgesia prior to ambulation to facilitate comfort and
cooperation. Pain is a common barrier to mobility.
,6. A patient is admitted for a colon resection. The preoperative order reads:
"Enema until clear." After the second enema, the patient reports severe
abdominal cramping and the return is still brown. Which action should the
nurse take?
A. Continue administering enemas as ordered.
B. Discontinue the enemas and notify the healthcare provider.
C. Administer a laxative instead.
D. Increase the enema solution temperature.
Rationale: Severe abdominal cramping can indicate bowel perforation or
obstruction. The return remaining brown despite multiple enemas may suggest an
obstruction. The nurse should discontinue the enemas and notify the healthcare
provider for further evaluation.
7. The nurse is preparing a patient for surgery. Which of the following is the
most important action to prevent wrong-site surgery?
A. Verify the surgical consent form is signed.
B. Ensure the patient has an ID band.
C. Participate in the surgical time-out with the entire surgical team.
D. Mark the surgical site with an "X."
Rationale: The surgical time-out is a mandatory safety check performed
immediately before the procedure by the entire surgical team to verify the correct
patient, correct procedure, and correct site. This is the final and most critical step in
preventing wrong-site surgery.
8. A patient is 4 hours post-appendectomy and has an NG tube to low
intermittent suction. The patient reports nausea. Which action should the
nurse take first?
A. Administer the prescribed antiemetic.
B. Irrigate the NG tube with sterile water.
C. Check the NG tube for placement and patency.
D. Notify the healthcare provider.
Rationale: Nausea in a patient with an NG tube may indicate tube displacement
or obstruction. The nurse should first check the NG tube for proper placement
and patency (by assessing output, checking the tube's position, and auscultating
for air). If the tube is not functioning properly, gastric contents can accumulate,
causing nausea.
, 9. A patient is receiving a blood transfusion postoperatively. Fifteen minutes
after the transfusion begins, the patient reports chills and low back pain.
Which action should the nurse take first?
A. Slow the transfusion rate.
B. Stop the transfusion immediately.
C. Administer diphenhydramine.
D. Notify the healthcare provider.
Rationale: The patient is exhibiting signs of an acute hemolytic transfusion
reaction (chills, low back pain). The immediate priority is to stop the
transfusion to prevent further complications. The nurse should then maintain IV
access with normal saline, notify the provider, and send the blood bag and tubing
to the blood bank.
10. A patient is 8 hours post-total knee replacement and has a patient-
controlled analgesia (PCA) pump. The patient reports pain at a level of 8 out
of 10 despite using the PCA. Which action should the nurse take first?
A. Increase the PCA dose.
B. Assess the patient's pain, PCA settings, and the IV site.
C. Administer a PRN oral analgesic.
D. Notify the healthcare provider.
Rationale: The nurse should first assess the patient to determine why the PCA is
ineffective. This includes assessing the pain characteristics, checking the PCA
pump settings, ensuring the IV site is patent, and evaluating for any complications.
This systematic assessment guides appropriate intervention.
11. The nurse is providing discharge teaching to a patient who had a
laparoscopic cholecystectomy. Which instruction is most important?
A. "You may resume all normal activities immediately."
B. "Report any fever, severe abdominal pain, or jaundice to your healthcare
provider."
C. "You may drive home from the hospital today."
D. "You can expect your incisions to drain for several days."
Rationale: Postoperative complications such as infection, bile leak, or retained
stones can present with fever, severe pain, or jaundice. The patient should be
instructed to report these signs immediately. Driving is contraindicated after
anesthesia, and incisions should not drain; drainage would indicate a problem.
Surgical Nursing Study Guide, Adult Patient
Care, Disease Management, Clinical Practice,
and Comprehensive Exam Review
1. A nurse is caring for a postoperative patient who is 6 hours post- abdominal
surgery. The patient reports sudden onset of severe chest pain and shortness
of breath. The nurse auscultates diminished breath sounds on the right side.
Which action should the nurse take first?
A. Administer prescribed PRN morphine.
B. Encourage deep breathing and coughing.
C. Notify the healthcare provider immediately.
D. Apply supplemental oxygen at 2 L/min via nasal cannula.
Rationale: The patient is exhibiting signs of a potential pulmonary embolism
(PE) or pneumothorax, both of which are life-threatening postoperative
complications. While applying oxygen is appropriate, the priority is to notify the
healthcare provider immediately for rapid evaluation and intervention. Sudden
chest pain, dyspnea, and diminished breath sounds are red flags that require
immediate medical attention.
2. A patient is 2 days post-total hip replacement. The nurse notes that the
patient's left calf is swollen, warm, and tender to palpation. Which nursing
action is most appropriate?
A. Apply a heating pad to the calf.
B. Massage the calf to improve circulation.
C. Measure the calf circumference and compare to the right leg.
D. Encourage the patient to ambulate in the hallway.
Rationale: The patient is exhibiting signs of a deep vein thrombosis (DVT) , a
serious postoperative complication. The nurse should measure the calf
circumference and compare it to the unaffected leg to assess for
asymmetry. Massage and heat are contraindicated as they can dislodge a
thrombus. Ambulation should be restricted until a DVT is ruled out.
3. A patient is scheduled for surgery and is NPO. The nurse notes that the
patient has a bedside glass of water. What is the nurse's priority action?
,A. Ignore the water since the patient is not drinking it.
B. Remove the water and remind the patient of NPO status.
C. Allow the patient to drink the water since surgery is hours away.
D. Document that the patient has water at the bedside.
Rationale: The priority is to remove the water and reinforce NPO (nothing by
mouth) teaching to prevent aspiration during surgery. The patient may forget they
are NPO and drink the water, which could lead to surgical cancellation or serious
complications.
4. A postoperative patient's vital signs are: BP 90/60 mmHg, HR 120 bpm, RR
24/min, temperature 38.5°C (101.3°F). The patient's surgical dressing is
saturated with bright red blood. Which nursing action should the nurse
perform first?
A. Administer antipyretics for the fever.
B. Apply pressure to the surgical site.
C. Increase the IV fluid rate.
D. Notify the surgeon.
Rationale: The patient is showing signs of hemorrhage (tachycardia,
hypotension, and bright red blood on the dressing). The immediate priority is
to apply direct pressure to the surgical site to control bleeding. While notifying
the surgeon and increasing fluids are important, they come after immediate
hemorrhage control.
5. A patient who had a cholecystectomy 24 hours ago has an order for early
ambulation. The patient refuses to get out of bed, stating, "It hurts too much."
Which nursing action is most appropriate?
A. Document the refusal and allow the patient to rest.
B. Assess the patient's pain level and administer prescribed analgesia before
ambulation.
C. Tell the patient that ambulation is mandatory.
D. Call the healthcare provider to cancel the order.
Rationale: Early ambulation is crucial postoperatively to prevent complications
such as DVT, pneumonia, and ileus. The nurse should assess the patient's pain
and administer analgesia prior to ambulation to facilitate comfort and
cooperation. Pain is a common barrier to mobility.
,6. A patient is admitted for a colon resection. The preoperative order reads:
"Enema until clear." After the second enema, the patient reports severe
abdominal cramping and the return is still brown. Which action should the
nurse take?
A. Continue administering enemas as ordered.
B. Discontinue the enemas and notify the healthcare provider.
C. Administer a laxative instead.
D. Increase the enema solution temperature.
Rationale: Severe abdominal cramping can indicate bowel perforation or
obstruction. The return remaining brown despite multiple enemas may suggest an
obstruction. The nurse should discontinue the enemas and notify the healthcare
provider for further evaluation.
7. The nurse is preparing a patient for surgery. Which of the following is the
most important action to prevent wrong-site surgery?
A. Verify the surgical consent form is signed.
B. Ensure the patient has an ID band.
C. Participate in the surgical time-out with the entire surgical team.
D. Mark the surgical site with an "X."
Rationale: The surgical time-out is a mandatory safety check performed
immediately before the procedure by the entire surgical team to verify the correct
patient, correct procedure, and correct site. This is the final and most critical step in
preventing wrong-site surgery.
8. A patient is 4 hours post-appendectomy and has an NG tube to low
intermittent suction. The patient reports nausea. Which action should the
nurse take first?
A. Administer the prescribed antiemetic.
B. Irrigate the NG tube with sterile water.
C. Check the NG tube for placement and patency.
D. Notify the healthcare provider.
Rationale: Nausea in a patient with an NG tube may indicate tube displacement
or obstruction. The nurse should first check the NG tube for proper placement
and patency (by assessing output, checking the tube's position, and auscultating
for air). If the tube is not functioning properly, gastric contents can accumulate,
causing nausea.
, 9. A patient is receiving a blood transfusion postoperatively. Fifteen minutes
after the transfusion begins, the patient reports chills and low back pain.
Which action should the nurse take first?
A. Slow the transfusion rate.
B. Stop the transfusion immediately.
C. Administer diphenhydramine.
D. Notify the healthcare provider.
Rationale: The patient is exhibiting signs of an acute hemolytic transfusion
reaction (chills, low back pain). The immediate priority is to stop the
transfusion to prevent further complications. The nurse should then maintain IV
access with normal saline, notify the provider, and send the blood bag and tubing
to the blood bank.
10. A patient is 8 hours post-total knee replacement and has a patient-
controlled analgesia (PCA) pump. The patient reports pain at a level of 8 out
of 10 despite using the PCA. Which action should the nurse take first?
A. Increase the PCA dose.
B. Assess the patient's pain, PCA settings, and the IV site.
C. Administer a PRN oral analgesic.
D. Notify the healthcare provider.
Rationale: The nurse should first assess the patient to determine why the PCA is
ineffective. This includes assessing the pain characteristics, checking the PCA
pump settings, ensuring the IV site is patent, and evaluating for any complications.
This systematic assessment guides appropriate intervention.
11. The nurse is providing discharge teaching to a patient who had a
laparoscopic cholecystectomy. Which instruction is most important?
A. "You may resume all normal activities immediately."
B. "Report any fever, severe abdominal pain, or jaundice to your healthcare
provider."
C. "You may drive home from the hospital today."
D. "You can expect your incisions to drain for several days."
Rationale: Postoperative complications such as infection, bile leak, or retained
stones can present with fever, severe pain, or jaundice. The patient should be
instructed to report these signs immediately. Driving is contraindicated after
anesthesia, and incisions should not drain; drainage would indicate a problem.
