NURS 201 Medical-Surgical Nursing – Promoting Wellness Week 13
Comprehensive Exam 2026 |WCU
1. A patient in the PACU is experiencing shivering and a rising temperature of
104.2°F shortly after general anesthesia. Which medication should the nurse
expect to administer immediately?
A. Acetaminophen
B. Furosemide
C. Dantrolene sodium
D. Pancuronium
Answer: C
Rationale: The patient’s symptoms are indicative of Malignant Hyperthermia (MH).
Dantrolene sodium is the specific skeletal muscle relaxant used to treat the hypermetabolic
crisis of MH.
2. A nurse is providing preoperative teaching to a client scheduled for elective
surgery. The client asks about the purpose of ‘Informed Consent.’ What is the
nurse’s primary role in this process?
A. Explaining the risks and benefits of the procedure
B. Obtaining the signature from the patient
C. Describing alternative treatments available
D. Witnessing the signature and ensuring the client is competent
Answer: D
Rationale: The surgeon is responsible for explaining the procedure. The nurse’s role is to
witness the signature and verify that the patient understands the information and is
competent to sign.
,3. During the assessment of a postoperative patient, the nurse notes a
protrusion of abdominal organs through the surgical incision. What is the
priority nursing action?
A. Cover the wound with sterile dressings moistened with normal saline
B. Attempt to push the organs back into the abdominal cavity
C. Place the patient in a High-Fowler’s position
D. Check the patient’s blood pressure and pulse immediately
Answer: A
Rationale: This is wound evisceration. The immediate priority is to cover the exposed
organs with sterile, saline-soaked dressings to keep them moist and prevent infection while
calling for help.
4. A client is 24 hours postoperative following abdominal surgery and has not
yet voided. What should be the nurse’s first action?
A. Insert a straight catheter immediately
B. Encourage increased fluid intake
C. Perform a bladder scan
D. Apply a warm compress to the suprapubic area
Answer: C
Rationale: Before invasive interventions or increasing fluids, the nurse must assess the
bladder volume objectively using a bladder scan to determine if the issue is retention or
decreased production.
, 5. Which laboratory value should the nurse prioritize for a client scheduled for
surgery who is taking warfarin?
A. Hemoglobin level
B. Partial thromboplastin time (PTT)
C. Platelet count
D. Prothrombin time (PT) and INR
Answer: D
Rationale: Warfarin is an anticoagulant monitored via PT and INR. High levels increase the
risk of intraoperative hemorrhage.
6. A patient is diagnosed with thrombocytopenia following chemotherapy.
Which nursing intervention is most appropriate?
A. Administering intramuscular injections for pain
B. Checking the rectal temperature every 4 hours
C. Encouraging the use of a soft-bristled toothbrush
D. Placing the patient in a semi-private room
Answer: C
Rationale: Thrombocytopenia is a low platelet count, increasing the risk of bleeding. Soft
toothbrushes prevent gum trauma; rectal temperatures and IM injections are
contraindicated due to bleeding risks.
7. In the preoperative phase, a patient reports an allergy to avocados and
bananas. For which complication should the surgical team be particularly
vigilant?
A. Latex allergy
B. Anaphylaxis to iodine
C. Malignant hyperthermia
D. Adverse reaction to succinylcholine
Answer: A
Comprehensive Exam 2026 |WCU
1. A patient in the PACU is experiencing shivering and a rising temperature of
104.2°F shortly after general anesthesia. Which medication should the nurse
expect to administer immediately?
A. Acetaminophen
B. Furosemide
C. Dantrolene sodium
D. Pancuronium
Answer: C
Rationale: The patient’s symptoms are indicative of Malignant Hyperthermia (MH).
Dantrolene sodium is the specific skeletal muscle relaxant used to treat the hypermetabolic
crisis of MH.
2. A nurse is providing preoperative teaching to a client scheduled for elective
surgery. The client asks about the purpose of ‘Informed Consent.’ What is the
nurse’s primary role in this process?
A. Explaining the risks and benefits of the procedure
B. Obtaining the signature from the patient
C. Describing alternative treatments available
D. Witnessing the signature and ensuring the client is competent
Answer: D
Rationale: The surgeon is responsible for explaining the procedure. The nurse’s role is to
witness the signature and verify that the patient understands the information and is
competent to sign.
,3. During the assessment of a postoperative patient, the nurse notes a
protrusion of abdominal organs through the surgical incision. What is the
priority nursing action?
A. Cover the wound with sterile dressings moistened with normal saline
B. Attempt to push the organs back into the abdominal cavity
C. Place the patient in a High-Fowler’s position
D. Check the patient’s blood pressure and pulse immediately
Answer: A
Rationale: This is wound evisceration. The immediate priority is to cover the exposed
organs with sterile, saline-soaked dressings to keep them moist and prevent infection while
calling for help.
4. A client is 24 hours postoperative following abdominal surgery and has not
yet voided. What should be the nurse’s first action?
A. Insert a straight catheter immediately
B. Encourage increased fluid intake
C. Perform a bladder scan
D. Apply a warm compress to the suprapubic area
Answer: C
Rationale: Before invasive interventions or increasing fluids, the nurse must assess the
bladder volume objectively using a bladder scan to determine if the issue is retention or
decreased production.
, 5. Which laboratory value should the nurse prioritize for a client scheduled for
surgery who is taking warfarin?
A. Hemoglobin level
B. Partial thromboplastin time (PTT)
C. Platelet count
D. Prothrombin time (PT) and INR
Answer: D
Rationale: Warfarin is an anticoagulant monitored via PT and INR. High levels increase the
risk of intraoperative hemorrhage.
6. A patient is diagnosed with thrombocytopenia following chemotherapy.
Which nursing intervention is most appropriate?
A. Administering intramuscular injections for pain
B. Checking the rectal temperature every 4 hours
C. Encouraging the use of a soft-bristled toothbrush
D. Placing the patient in a semi-private room
Answer: C
Rationale: Thrombocytopenia is a low platelet count, increasing the risk of bleeding. Soft
toothbrushes prevent gum trauma; rectal temperatures and IM injections are
contraindicated due to bleeding risks.
7. In the preoperative phase, a patient reports an allergy to avocados and
bananas. For which complication should the surgical team be particularly
vigilant?
A. Latex allergy
B. Anaphylaxis to iodine
C. Malignant hyperthermia
D. Adverse reaction to succinylcholine
Answer: A
