Page 1 of 91
NU 185 MEDICAL-SURGICAL NURSING II
COMPREHENSIVE EXAM QUESTIONS WITH VERIFIED
QUESTIONS DETAILED RATIONALES GRADED A+
NU 185 Medical-Surgical Nursing II Comprehensive Exam — Questions
SECTION 1: PERIOPERATIVE NURSING CARE (Questions 1–25)
1. A nurse is caring for a patient who is 48 hours post-operative following abdominal surgery.
The nurse notes the wound has dehisced and a loop of bowel is protruding. Which action
should the nurse take first?
A) Attempt to gently reinsert the protruding organ into the abdominal cavity
B) Apply a sterile dressing moistened with sterile normal saline
C) Place the patient in a High-Fowler's position to reduce abdominal pressure
D) Notify the surgeon immediately before performing any other interventions
Answer: B
Rationale: Evisceration is a medical emergency. The nurse should first cover the protruding
organs with sterile dressings moistened with sterile normal saline to prevent drying and
infection, then notify the surgeon .
2. A client is scheduled for surgery and has a serum potassium level of 5.8 mEq/L. Which
action should the nurse take first?
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A) Document the finding and continue preparation
B) Notify the surgeon immediately
C) Administer potassium chloride IV
D) Encourage a high-potassium diet
Answer: B
Rationale: Hyperkalemia (K+ > 5.0 mEq/L) can cause life-threatening arrhythmias during
surgery. The surgeon must be notified immediately .
3. A client is NPO for surgery and requests water 1 hour before the procedure. What is the
nurse's best response?
A) Provide a small sip of water
B) Remind the client of NPO status and explain aspiration risk
C) Call the surgeon for permission
D) Give the water and document it
Answer: B
Rationale: NPO status prevents aspiration during anesthesia. The nurse should reinforce NPO
instructions and explain the rationale .
4. During surgery, a client develops muscle rigidity, tachycardia, and rising temperature.
Which medication should the nurse anticipate?
A) Naloxone
B) Dantrolene sodium
C) Atropine
D) Epinephrine
Answer: B
Rationale: Malignant hyperthermia is treated with dantrolene sodium, which relaxes skeletal
muscle .
5. A postoperative client is at risk for atelectasis. Which nursing intervention is most effective
in preventing this complication?
A) Administering pain medication
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B) Encouraging incentive spirometry every hour while awake
C) Maintaining bed rest
D) Restricting fluid intake
Answer: B
Rationale: Incentive spirometry promotes lung expansion and prevents alveolar collapse
(atelectasis) by encouraging deep breathing .
6. A client is being prepared for surgery and has a history of diabetes. Which preoperative
instruction is most important?
A) Take all diabetes medications as usual
B) Monitor blood glucose closely and follow the surgeon's orders regarding insulin
C) Skip breakfast but take oral hypoglycemics
D) Drink orange juice before surgery
Answer: B
Rationale: Blood glucose should be monitored closely in diabetic patients undergoing surgery.
Insulin or oral agent adjustments are typically ordered by the surgeon or anesthesiologist .
7. A postoperative client develops a fever, tachycardia, and hypotension. Which complication
is most likely?
A) Atelectasis
B) Wound infection
C) Sepsis
D) DVT
Answer: C
Rationale: Fever, tachycardia, and hypotension are signs of sepsis, a life-threatening systemic
infection requiring immediate intervention .
8. A nurse is teaching a preoperative client about postoperative leg exercises. What is the
primary purpose of these exercises?
A) To strengthen leg muscles
B) To prevent deep vein thrombosis
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C) To improve balance
D) To reduce pain
Answer: B
Rationale: Leg exercises promote venous return and prevent venous stasis, reducing the risk of
DVT .
9. A client is scheduled for surgery and reports an allergy to latex. Which action should the
nurse take?
A) Document the allergy and ensure a latex-free environment
B) Ignore the allergy if it is mild
C) Administer diphenhydramine preoperatively
D) Use latex gloves with extra caution
Answer: A
Rationale: A latex-free environment is essential for patients with latex allergy to prevent
anaphylaxis during surgery .
10. A postoperative client's wound is healing by primary intention. Which characteristic is
expected?
A) Granulation tissue fills the wound
B) Wound edges are approximated with minimal scarring
C) Wound is left open to heal
D) Extensive scarring occurs
Answer: B
Rationale: Primary intention healing occurs when wound edges are approximated (sutured or
stapled), resulting in minimal scarring .
11. A client is being prepared for surgery and asks why the nurse is marking the surgical site.
What is the nurse's best response?
A) "It helps the surgeon know where to make the incision."
B) "It is done to prevent wrong-site surgery."
C) "It is for billing purposes."
NU 185 MEDICAL-SURGICAL NURSING II
COMPREHENSIVE EXAM QUESTIONS WITH VERIFIED
QUESTIONS DETAILED RATIONALES GRADED A+
NU 185 Medical-Surgical Nursing II Comprehensive Exam — Questions
SECTION 1: PERIOPERATIVE NURSING CARE (Questions 1–25)
1. A nurse is caring for a patient who is 48 hours post-operative following abdominal surgery.
The nurse notes the wound has dehisced and a loop of bowel is protruding. Which action
should the nurse take first?
A) Attempt to gently reinsert the protruding organ into the abdominal cavity
B) Apply a sterile dressing moistened with sterile normal saline
C) Place the patient in a High-Fowler's position to reduce abdominal pressure
D) Notify the surgeon immediately before performing any other interventions
Answer: B
Rationale: Evisceration is a medical emergency. The nurse should first cover the protruding
organs with sterile dressings moistened with sterile normal saline to prevent drying and
infection, then notify the surgeon .
2. A client is scheduled for surgery and has a serum potassium level of 5.8 mEq/L. Which
action should the nurse take first?
,Page 2 of 91
A) Document the finding and continue preparation
B) Notify the surgeon immediately
C) Administer potassium chloride IV
D) Encourage a high-potassium diet
Answer: B
Rationale: Hyperkalemia (K+ > 5.0 mEq/L) can cause life-threatening arrhythmias during
surgery. The surgeon must be notified immediately .
3. A client is NPO for surgery and requests water 1 hour before the procedure. What is the
nurse's best response?
A) Provide a small sip of water
B) Remind the client of NPO status and explain aspiration risk
C) Call the surgeon for permission
D) Give the water and document it
Answer: B
Rationale: NPO status prevents aspiration during anesthesia. The nurse should reinforce NPO
instructions and explain the rationale .
4. During surgery, a client develops muscle rigidity, tachycardia, and rising temperature.
Which medication should the nurse anticipate?
A) Naloxone
B) Dantrolene sodium
C) Atropine
D) Epinephrine
Answer: B
Rationale: Malignant hyperthermia is treated with dantrolene sodium, which relaxes skeletal
muscle .
5. A postoperative client is at risk for atelectasis. Which nursing intervention is most effective
in preventing this complication?
A) Administering pain medication
,Page 3 of 91
B) Encouraging incentive spirometry every hour while awake
C) Maintaining bed rest
D) Restricting fluid intake
Answer: B
Rationale: Incentive spirometry promotes lung expansion and prevents alveolar collapse
(atelectasis) by encouraging deep breathing .
6. A client is being prepared for surgery and has a history of diabetes. Which preoperative
instruction is most important?
A) Take all diabetes medications as usual
B) Monitor blood glucose closely and follow the surgeon's orders regarding insulin
C) Skip breakfast but take oral hypoglycemics
D) Drink orange juice before surgery
Answer: B
Rationale: Blood glucose should be monitored closely in diabetic patients undergoing surgery.
Insulin or oral agent adjustments are typically ordered by the surgeon or anesthesiologist .
7. A postoperative client develops a fever, tachycardia, and hypotension. Which complication
is most likely?
A) Atelectasis
B) Wound infection
C) Sepsis
D) DVT
Answer: C
Rationale: Fever, tachycardia, and hypotension are signs of sepsis, a life-threatening systemic
infection requiring immediate intervention .
8. A nurse is teaching a preoperative client about postoperative leg exercises. What is the
primary purpose of these exercises?
A) To strengthen leg muscles
B) To prevent deep vein thrombosis
, Page 4 of 91
C) To improve balance
D) To reduce pain
Answer: B
Rationale: Leg exercises promote venous return and prevent venous stasis, reducing the risk of
DVT .
9. A client is scheduled for surgery and reports an allergy to latex. Which action should the
nurse take?
A) Document the allergy and ensure a latex-free environment
B) Ignore the allergy if it is mild
C) Administer diphenhydramine preoperatively
D) Use latex gloves with extra caution
Answer: A
Rationale: A latex-free environment is essential for patients with latex allergy to prevent
anaphylaxis during surgery .
10. A postoperative client's wound is healing by primary intention. Which characteristic is
expected?
A) Granulation tissue fills the wound
B) Wound edges are approximated with minimal scarring
C) Wound is left open to heal
D) Extensive scarring occurs
Answer: B
Rationale: Primary intention healing occurs when wound edges are approximated (sutured or
stapled), resulting in minimal scarring .
11. A client is being prepared for surgery and asks why the nurse is marking the surgical site.
What is the nurse's best response?
A) "It helps the surgeon know where to make the incision."
B) "It is done to prevent wrong-site surgery."
C) "It is for billing purposes."
