NSG 3250 Adult Health I Exam 2 Complete
Test Bank Galen College of Nursing | Units
3 & 4 | With Questions And Answers &
Detailed Rationales
### SECTION 1: PERIOPERATIVE CARE (Questions 1-25)
**Question 1**
A patient is admitted with a Glasgow Coma Scale (GCS) score of 7. What is the nurse's
priority action?
A) Reassess the patient in 15 minutes
B) Prepare for immediate intubation
C) Administer a bolus of IV fluids
D) Position the patient in Trendelenburg position
**Answer: B**
**Rationale:** A GCS score of 8 or less indicates severe brain injury and loss of
protective airway reflexes. The priority is to secure the airway via intubation to prevent
aspiration and hypoxia.
---
**Question 2**
A postoperative patient suddenly becomes restless and anxious, and the nurse notes
pink, frothy sputum. What is the priority nursing intervention?
A) Elevate the head of the bed and apply high-flow oxygen
,B) Administer morphine sulfate as prescribed
C) Place the patient in a supine position
D) Increase the IV fluid rate
**Answer: A**
**Rationale:** Pink, frothy sputum indicates flash pulmonary edema, a medical
emergency. The nurse must immediately elevate the head of the bed to reduce venous
return and apply high-flow oxygen to support oxygenation.
---
**Question 3**
A patient is scheduled for surgery and reports taking aspirin daily. The nurse should:
A) Administer the aspirin as scheduled
B) Notify the provider and hold the aspirin
C) Double the dose for surgical prophylaxis
D) Switch to ibuprofen
**Answer: B**
**Rationale:** Aspirin inhibits platelet aggregation and increases the risk of bleeding
during surgery. It should be held for 5-7 days before surgery per provider orders.
---
**Question 4**
Which of the following is the most important preoperative assessment finding that
requires notification of the provider?
A) Blood pressure 138/88 mmHg
,B) Heart rate 88 bpm
C) Temperature 101.2°F (38.4°C)
D) Respiratory rate 18 breaths/min
**Answer: C**
**Rationale:** A temperature of 101.2°F indicates a possible infection, which may
require postponement of surgery. Fever increases the risk of complications and may
indicate an underlying condition.
---
**Question 5**
A patient is NPO for surgery. Which of the following is the primary rationale for this
restriction?
A) To prevent constipation
B) To reduce the risk of aspiration during anesthesia
C) To promote wound healing
D) To decrease metabolic rate
**Answer: B**
**Rationale:** NPO status prevents aspiration of gastric contents during anesthesia
induction, which can lead to aspiration pneumonia. The stomach should be empty to
reduce this risk.
---
**Question 6**
A postoperative patient develops a fever on the first day after surgery. Which of the
following is the most likely cause?
, A) Wound infection
B) Atelectasis
C) Urinary tract infection
D) Deep vein thrombosis
**Answer: B**
**Rationale:** Atelectasis is the most common cause of fever in the first 24-48 hours
postoperatively. It results from decreased lung expansion and retained secretions.
---
**Question 7**
Which of the following is a priority nursing intervention to prevent venous
thromboembolism (VTE) in a postoperative patient?
A) Encourage coughing and deep breathing
B) Apply sequential compression devices (SCDs)
C) Restrict oral fluids
D) Keep the patient in a supine position
**Answer: B**
**Rationale:** SCDs promote venous return and prevent stasis, reducing the risk of
deep vein thrombosis. Other interventions include early ambulation and anticoagulation
therapy as ordered.
---
**Question 8**
Test Bank Galen College of Nursing | Units
3 & 4 | With Questions And Answers &
Detailed Rationales
### SECTION 1: PERIOPERATIVE CARE (Questions 1-25)
**Question 1**
A patient is admitted with a Glasgow Coma Scale (GCS) score of 7. What is the nurse's
priority action?
A) Reassess the patient in 15 minutes
B) Prepare for immediate intubation
C) Administer a bolus of IV fluids
D) Position the patient in Trendelenburg position
**Answer: B**
**Rationale:** A GCS score of 8 or less indicates severe brain injury and loss of
protective airway reflexes. The priority is to secure the airway via intubation to prevent
aspiration and hypoxia.
---
**Question 2**
A postoperative patient suddenly becomes restless and anxious, and the nurse notes
pink, frothy sputum. What is the priority nursing intervention?
A) Elevate the head of the bed and apply high-flow oxygen
,B) Administer morphine sulfate as prescribed
C) Place the patient in a supine position
D) Increase the IV fluid rate
**Answer: A**
**Rationale:** Pink, frothy sputum indicates flash pulmonary edema, a medical
emergency. The nurse must immediately elevate the head of the bed to reduce venous
return and apply high-flow oxygen to support oxygenation.
---
**Question 3**
A patient is scheduled for surgery and reports taking aspirin daily. The nurse should:
A) Administer the aspirin as scheduled
B) Notify the provider and hold the aspirin
C) Double the dose for surgical prophylaxis
D) Switch to ibuprofen
**Answer: B**
**Rationale:** Aspirin inhibits platelet aggregation and increases the risk of bleeding
during surgery. It should be held for 5-7 days before surgery per provider orders.
---
**Question 4**
Which of the following is the most important preoperative assessment finding that
requires notification of the provider?
A) Blood pressure 138/88 mmHg
,B) Heart rate 88 bpm
C) Temperature 101.2°F (38.4°C)
D) Respiratory rate 18 breaths/min
**Answer: C**
**Rationale:** A temperature of 101.2°F indicates a possible infection, which may
require postponement of surgery. Fever increases the risk of complications and may
indicate an underlying condition.
---
**Question 5**
A patient is NPO for surgery. Which of the following is the primary rationale for this
restriction?
A) To prevent constipation
B) To reduce the risk of aspiration during anesthesia
C) To promote wound healing
D) To decrease metabolic rate
**Answer: B**
**Rationale:** NPO status prevents aspiration of gastric contents during anesthesia
induction, which can lead to aspiration pneumonia. The stomach should be empty to
reduce this risk.
---
**Question 6**
A postoperative patient develops a fever on the first day after surgery. Which of the
following is the most likely cause?
, A) Wound infection
B) Atelectasis
C) Urinary tract infection
D) Deep vein thrombosis
**Answer: B**
**Rationale:** Atelectasis is the most common cause of fever in the first 24-48 hours
postoperatively. It results from decreased lung expansion and retained secretions.
---
**Question 7**
Which of the following is a priority nursing intervention to prevent venous
thromboembolism (VTE) in a postoperative patient?
A) Encourage coughing and deep breathing
B) Apply sequential compression devices (SCDs)
C) Restrict oral fluids
D) Keep the patient in a supine position
**Answer: B**
**Rationale:** SCDs promote venous return and prevent stasis, reducing the risk of
deep vein thrombosis. Other interventions include early ambulation and anticoagulation
therapy as ordered.
---
**Question 8**
