,NUR 201 Final Exam Medical-Surgical Nursing I Questions And
Answers 2026/2027 Jersey College
Q1. A competent adult refuses a recommended blood transfusion
after the risks and benefits have been explained. Which nursing
action best respects the patient's autonomy?
A) Ask the family to override the refusal
B) Respect the decision and communicate it to the healthcare team
C) Administer the transfusion because it is medically indicated
D) Delay documenting the refusal until the patient's condition worsens
Correct Answer: B) Respect the decision and communicate it to the
healthcare team
Rationale: A competent patient has the right to accept or refuse treatment
after receiving adequate information. The nurse should respect and
document the decision while communicating it appropriately.
Q2. A patient with chronic pain rates the pain as 8/10 but is
laughing with a visitor. How should the nurse interpret this finding?
A) The patient is exaggerating the pain
B) The pain rating is invalid because the patient appears comfortable
C) Analgesia should be withheld until objective signs develop
D) Behavioral appearance does not invalidate the patient's self-report of pain
Correct Answer: D) Behavioral appearance does not invalidate the patient's
self-report of pain
Rationale: Pain is subjective, and patients may display pain differently. Self-
report remains the most reliable indicator when the patient can
communicate.
Q3. After administering an IV opioid for severe postoperative pain,
which nursing action is essential?
A) Reassess pain, sedation, respiratory status, and treatment response
B) Wait until the next scheduled medication time before reassessing
C) Encourage the patient to sleep without further observation
D) Document effectiveness before evaluating the patient
Correct Answer: A) Reassess pain, sedation, respiratory status, and
treatment response
,Rationale: Analgesic therapy requires reassessment to determine
effectiveness and detect adverse effects such as excessive sedation or
respiratory depression.
Q4. Which preoperative finding should be reported because it
substantially increases the risk of surgical bleeding?
A) Wearing prescription glasses
B) Seasonal pollen allergy
C) Regular use of an anticoagulant medication
D) History of motion sickness
Correct Answer: C) Regular use of an anticoagulant medication
Rationale: Anticoagulants interfere with normal clot formation and may
increase perioperative bleeding risk. The surgical team must know about
their use before the procedure.
Q5. A patient scheduled for surgery says, “I changed my mind and
don't want this operation.” What is the nurse's best response?
A) Explain that the signed consent cannot be withdrawn
B) Stop preparations and notify the surgical team of the patient's decision
C) Ask the family to persuade the patient
D) Administer the preoperative sedative to reduce anxiety
Correct Answer: B) Stop preparations and notify the surgical team of the
patient's decision
Rationale: Consent is voluntary and may be withdrawn before the
procedure. The patient's decision must be respected and communicated
before surgery proceeds.
Q6. Which postoperative finding is most consistent with wound
dehiscence?
A) Separation of previously approximated wound edges
B) Mild bruising around an intact incision
C) Small amount of serous drainage on the first postoperative day
D) Temporary incisional discomfort during coughing
Correct Answer: A) Separation of previously approximated wound edges
Rationale: Dehiscence is partial or complete separation of a surgical
incision, usually involving deeper wound layers.
, Q7. A patient coughs forcefully after abdominal surgery, and
abdominal organs become visible through the incision. What should
the nurse do first?
A) Attempt to replace the organs into the abdominal cavity
B) Apply a dry pressure dressing tightly
C) Ask the patient to stand for better visualization
D) Cover the exposed tissue with sterile saline-moistened dressings and
obtain immediate surgical assistance
Correct Answer: D) Cover the exposed tissue with sterile saline-moistened
dressings and obtain immediate surgical assistance
Rationale: Evisceration is a surgical emergency. Moist sterile dressings
protect exposed tissue while urgent surgical intervention is arranged.
Q8. Which factor most directly contributes to postoperative venous
stasis?
A) Increased dietary protein
B) Use of incentive spirometry
C) Prolonged immobility
D) Frequent repositioning
Correct Answer: C) Prolonged immobility
Rationale: Immobility reduces contraction of the calf muscles that normally
assist venous return, increasing the risk of venous stasis and thrombosis.
Q9. Why is adequate protein intake important during recovery from
major surgery?
A) Protein supplies amino acids needed for tissue repair and collagen
formation
B) Protein prevents every postoperative infection
C) Protein eliminates the need for vitamin intake
D) Protein directly dissolves surgical scar tissue
Correct Answer: A) Protein supplies amino acids needed for tissue repair and
collagen formation
Rationale: Wound healing requires adequate protein for synthesis of new
tissue, collagen, enzymes, and immune components.
Q10. A postoperative patient becomes increasingly restless before
showing obvious cyanosis. What should the nurse suspect?
Answers 2026/2027 Jersey College
Q1. A competent adult refuses a recommended blood transfusion
after the risks and benefits have been explained. Which nursing
action best respects the patient's autonomy?
A) Ask the family to override the refusal
B) Respect the decision and communicate it to the healthcare team
C) Administer the transfusion because it is medically indicated
D) Delay documenting the refusal until the patient's condition worsens
Correct Answer: B) Respect the decision and communicate it to the
healthcare team
Rationale: A competent patient has the right to accept or refuse treatment
after receiving adequate information. The nurse should respect and
document the decision while communicating it appropriately.
Q2. A patient with chronic pain rates the pain as 8/10 but is
laughing with a visitor. How should the nurse interpret this finding?
A) The patient is exaggerating the pain
B) The pain rating is invalid because the patient appears comfortable
C) Analgesia should be withheld until objective signs develop
D) Behavioral appearance does not invalidate the patient's self-report of pain
Correct Answer: D) Behavioral appearance does not invalidate the patient's
self-report of pain
Rationale: Pain is subjective, and patients may display pain differently. Self-
report remains the most reliable indicator when the patient can
communicate.
Q3. After administering an IV opioid for severe postoperative pain,
which nursing action is essential?
A) Reassess pain, sedation, respiratory status, and treatment response
B) Wait until the next scheduled medication time before reassessing
C) Encourage the patient to sleep without further observation
D) Document effectiveness before evaluating the patient
Correct Answer: A) Reassess pain, sedation, respiratory status, and
treatment response
,Rationale: Analgesic therapy requires reassessment to determine
effectiveness and detect adverse effects such as excessive sedation or
respiratory depression.
Q4. Which preoperative finding should be reported because it
substantially increases the risk of surgical bleeding?
A) Wearing prescription glasses
B) Seasonal pollen allergy
C) Regular use of an anticoagulant medication
D) History of motion sickness
Correct Answer: C) Regular use of an anticoagulant medication
Rationale: Anticoagulants interfere with normal clot formation and may
increase perioperative bleeding risk. The surgical team must know about
their use before the procedure.
Q5. A patient scheduled for surgery says, “I changed my mind and
don't want this operation.” What is the nurse's best response?
A) Explain that the signed consent cannot be withdrawn
B) Stop preparations and notify the surgical team of the patient's decision
C) Ask the family to persuade the patient
D) Administer the preoperative sedative to reduce anxiety
Correct Answer: B) Stop preparations and notify the surgical team of the
patient's decision
Rationale: Consent is voluntary and may be withdrawn before the
procedure. The patient's decision must be respected and communicated
before surgery proceeds.
Q6. Which postoperative finding is most consistent with wound
dehiscence?
A) Separation of previously approximated wound edges
B) Mild bruising around an intact incision
C) Small amount of serous drainage on the first postoperative day
D) Temporary incisional discomfort during coughing
Correct Answer: A) Separation of previously approximated wound edges
Rationale: Dehiscence is partial or complete separation of a surgical
incision, usually involving deeper wound layers.
, Q7. A patient coughs forcefully after abdominal surgery, and
abdominal organs become visible through the incision. What should
the nurse do first?
A) Attempt to replace the organs into the abdominal cavity
B) Apply a dry pressure dressing tightly
C) Ask the patient to stand for better visualization
D) Cover the exposed tissue with sterile saline-moistened dressings and
obtain immediate surgical assistance
Correct Answer: D) Cover the exposed tissue with sterile saline-moistened
dressings and obtain immediate surgical assistance
Rationale: Evisceration is a surgical emergency. Moist sterile dressings
protect exposed tissue while urgent surgical intervention is arranged.
Q8. Which factor most directly contributes to postoperative venous
stasis?
A) Increased dietary protein
B) Use of incentive spirometry
C) Prolonged immobility
D) Frequent repositioning
Correct Answer: C) Prolonged immobility
Rationale: Immobility reduces contraction of the calf muscles that normally
assist venous return, increasing the risk of venous stasis and thrombosis.
Q9. Why is adequate protein intake important during recovery from
major surgery?
A) Protein supplies amino acids needed for tissue repair and collagen
formation
B) Protein prevents every postoperative infection
C) Protein eliminates the need for vitamin intake
D) Protein directly dissolves surgical scar tissue
Correct Answer: A) Protein supplies amino acids needed for tissue repair and
collagen formation
Rationale: Wound healing requires adequate protein for synthesis of new
tissue, collagen, enzymes, and immune components.
Q10. A postoperative patient becomes increasingly restless before
showing obvious cyanosis. What should the nurse suspect?
