Galen College NUR 242 Exam 1 (pdf) | 2026/2027 | Med-Surg Q&A |
Medical-Surgical Nursing
1. A patient is scheduled for surgery and reports taking St. John's Wort for
mild depression. What is the priority nursing action?
A) Document the supplement and proceed with surgery.
B) Instruct the patient to stop taking St. John's Wort 2 weeks prior to surgery.
C) Tell the patient to take the usual dose on the morning of surgery.
D) Ask the provider to prescribe a stronger SSRI.
Correct Answer: Instruct the patient to stop taking St. John's Wort 2 weeks
prior to surgery.
Rationale: St. John's Wort can interact with anesthetic agents and
postoperative opioids, leading to serotonin syndrome. It also increases the
metabolism of other drugs. It should be discontinued at least 2 to 3 weeks
prior to surgery to prevent these life-threatening complications.
2. A nurse witnesses another nurse providing care without performing proper
hand hygiene and reports this to the charge nurse. The charge nurse refuses
to take action because the other nurse is a friend. This is an example of:
A) Ethical dilemma
B) Moral distress
C) Whistleblowing
D) Professional negligence
Correct Answer: Moral distress
Rationale: Moral distress occurs when a nurse knows the right thing to do but
is prevented from doing it due to institutional or hierarchical constraints. The
charge nurse's refusal to address the unsafe practice creates a conflict
,between the reporting nurse's ethical obligation and the inability to effect
change.
3. A patient in the post-anesthesia care unit (PACU) is restless, moaning, and
thrashing. Vital signs show blood pressure 170/100 mmHg, heart rate 110
bpm, and respiratory rate 28 bpm. What is the priority nursing intervention?
A) Administer a PRN antiemetic.
B) Apply soft wrist restraints.
C) Assess for a full bladder.
D) Administer a PRN analgesic for pain.
Correct Answer: Assess for a full bladder.
Rationale: Restlessness, hypertension, and tachycardia in the PACU are often
signs of a full bladder or pain. A distended bladder is a common cause of
postoperative agitation. The nurse should first assess for bladder distention
before administering medications or applying restraints.
4. A patient develops a localized red area on the coccyx that is non-
blanchable. What stage of pressure injury is this?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Correct Answer: Stage 1
Rationale: A Stage 1 pressure injury is characterized by intact skin with a
localized area of non-blanchable erythema. The skin is intact and may be
painful or have temperature changes, but there is no open ulceration.
,5. Which of the following interventions helps prevent the complications of
immobility? (Select all that apply.)
A) Utilizing a waffle mattress to reduce the need for repositioning
B) Applying TEDs/SCDs
C) Rubbing reddened areas
D) Limiting fluid intake
E) Performing range of motion exercises
Correct Answer: B) Applying TEDs/SCDs and E) Performing range of motion
exercises
Rationale: TEDs/SCDs prevent venous stasis and DVT. ROM exercises
maintain joint mobility and prevent contractures. Repositioning should still
occur every 2 hours regardless of the mattress. Rubbing reddened areas
increases the risk of skin breakdown, and adequate hydration is essential for
skin health.
6. The circulating nurse notes that a surgical patient's temperature has
dropped to 35.8°C (96.4°F). This patient is at greatest risk for which
postoperative complication?
A) Malignant hyperthermia
B) Increased blood loss
C) Surgical site infection and delayed wound healing
D) Hyperactive bowel sounds
Correct Answer: Surgical site infection and delayed wound healing
Rationale: Mild perioperative hypothermia causes peripheral
vasoconstriction, decreasing oxygen delivery to the wound and impairing
, leukocyte function and collagen synthesis. This significantly increases the
risk of surgical site infections and delays wound healing.
7. An immobile patient is at risk for which of the following complications?
(Select all that apply.)
A) Deep vein thrombosis (DVT)
B) Pneumonia
C) Constipation
D) Skin breakdown
E) Hypertension
Correct Answer: A) Deep vein thrombosis (DVT), B) Pneumonia, C)
Constipation, and D) Skin breakdown
Rationale: Immobility leads to venous stasis (DVT), hypostatic pneumonia,
decreased peristalsis (constipation), and pressure on skin surfaces
(breakdown). Hypertension is not a direct complication of immobility;
hypotension from decreased vascular tone is more common.
8. An 85-year-old woman is admitted to the hospital. What factors put her at
risk for pressure injuries? (Select all that apply.)
A) Immobility
B) Incontinence
C) Diabetes or PVD
D) Malnutrition or dehydration
E) Decreased sensory perception
Correct Answer: All of the above
Medical-Surgical Nursing
1. A patient is scheduled for surgery and reports taking St. John's Wort for
mild depression. What is the priority nursing action?
A) Document the supplement and proceed with surgery.
B) Instruct the patient to stop taking St. John's Wort 2 weeks prior to surgery.
C) Tell the patient to take the usual dose on the morning of surgery.
D) Ask the provider to prescribe a stronger SSRI.
Correct Answer: Instruct the patient to stop taking St. John's Wort 2 weeks
prior to surgery.
Rationale: St. John's Wort can interact with anesthetic agents and
postoperative opioids, leading to serotonin syndrome. It also increases the
metabolism of other drugs. It should be discontinued at least 2 to 3 weeks
prior to surgery to prevent these life-threatening complications.
2. A nurse witnesses another nurse providing care without performing proper
hand hygiene and reports this to the charge nurse. The charge nurse refuses
to take action because the other nurse is a friend. This is an example of:
A) Ethical dilemma
B) Moral distress
C) Whistleblowing
D) Professional negligence
Correct Answer: Moral distress
Rationale: Moral distress occurs when a nurse knows the right thing to do but
is prevented from doing it due to institutional or hierarchical constraints. The
charge nurse's refusal to address the unsafe practice creates a conflict
,between the reporting nurse's ethical obligation and the inability to effect
change.
3. A patient in the post-anesthesia care unit (PACU) is restless, moaning, and
thrashing. Vital signs show blood pressure 170/100 mmHg, heart rate 110
bpm, and respiratory rate 28 bpm. What is the priority nursing intervention?
A) Administer a PRN antiemetic.
B) Apply soft wrist restraints.
C) Assess for a full bladder.
D) Administer a PRN analgesic for pain.
Correct Answer: Assess for a full bladder.
Rationale: Restlessness, hypertension, and tachycardia in the PACU are often
signs of a full bladder or pain. A distended bladder is a common cause of
postoperative agitation. The nurse should first assess for bladder distention
before administering medications or applying restraints.
4. A patient develops a localized red area on the coccyx that is non-
blanchable. What stage of pressure injury is this?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Correct Answer: Stage 1
Rationale: A Stage 1 pressure injury is characterized by intact skin with a
localized area of non-blanchable erythema. The skin is intact and may be
painful or have temperature changes, but there is no open ulceration.
,5. Which of the following interventions helps prevent the complications of
immobility? (Select all that apply.)
A) Utilizing a waffle mattress to reduce the need for repositioning
B) Applying TEDs/SCDs
C) Rubbing reddened areas
D) Limiting fluid intake
E) Performing range of motion exercises
Correct Answer: B) Applying TEDs/SCDs and E) Performing range of motion
exercises
Rationale: TEDs/SCDs prevent venous stasis and DVT. ROM exercises
maintain joint mobility and prevent contractures. Repositioning should still
occur every 2 hours regardless of the mattress. Rubbing reddened areas
increases the risk of skin breakdown, and adequate hydration is essential for
skin health.
6. The circulating nurse notes that a surgical patient's temperature has
dropped to 35.8°C (96.4°F). This patient is at greatest risk for which
postoperative complication?
A) Malignant hyperthermia
B) Increased blood loss
C) Surgical site infection and delayed wound healing
D) Hyperactive bowel sounds
Correct Answer: Surgical site infection and delayed wound healing
Rationale: Mild perioperative hypothermia causes peripheral
vasoconstriction, decreasing oxygen delivery to the wound and impairing
, leukocyte function and collagen synthesis. This significantly increases the
risk of surgical site infections and delays wound healing.
7. An immobile patient is at risk for which of the following complications?
(Select all that apply.)
A) Deep vein thrombosis (DVT)
B) Pneumonia
C) Constipation
D) Skin breakdown
E) Hypertension
Correct Answer: A) Deep vein thrombosis (DVT), B) Pneumonia, C)
Constipation, and D) Skin breakdown
Rationale: Immobility leads to venous stasis (DVT), hypostatic pneumonia,
decreased peristalsis (constipation), and pressure on skin surfaces
(breakdown). Hypertension is not a direct complication of immobility;
hypotension from decreased vascular tone is more common.
8. An 85-year-old woman is admitted to the hospital. What factors put her at
risk for pressure injuries? (Select all that apply.)
A) Immobility
B) Incontinence
C) Diabetes or PVD
D) Malnutrition or dehydration
E) Decreased sensory perception
Correct Answer: All of the above
