NURS 121L-A Introduction to Medical-Surgical Nursing Practicum -
Week 2 Comprehensive Quiz 2026 |WCU
1. A nurse is caring for a postoperative patient who suddenly develops
restlessness, tachycardia, and a decrease in oxygen saturation. Which action
should the nurse take first?
A. Administer prescribed pain medication
B. Assess airway patency and respiratory rate
C. Notify the surgeon immediately
D. Check the patient’s temperature
Answer: B
Rationale: In postoperative care, the priority is always the ABCs (Airway, Breathing,
Circulation). Restlessness and tachycardia are early signs of hypoxia; assessing the airway
and breathing is the first action.
2. When preparing a sterile field for a dressing change, which action by the
nurse would contaminate the field?
A. Placing sterile items within the 1-inch border of the field
B. Opening the outermost flap away from the body
C. Keeping the sterile field above waist level
D. Holding the sterile drape by the corners
Answer: A
Rationale: The 1-inch (2.5 cm) border around a sterile field is considered contaminated.
Any item placed within this border is no longer sterile.
,3. A patient with a history of deep vein thrombosis (DVT) is scheduled for
surgery. Which preoperative finding should be reported to the surgeon
immediately?
A. A blood pressure of 138/88 mmHg
B. A serum potassium level of 3.8 mEq/L
C. An International Normalized Ratio (INR) of 4.2
D. Anxiety regarding the surgical outcome
Answer: C
Rationale: An INR of 4.2 is significantly elevated (therapeutic range for DVT is usually 2.0-
3.0), indicating a high risk for surgical hemorrhage and must be reported.
4. The nurse is implementing standard precautions. For which patient scenario is
a mask and eye protection required?
A. Emptying a urinary catheter bag
B. Assisting a patient with a bed bath
C. Suctioning a patient with a tracheotomy
D. Measuring a patient’s blood pressure
Answer: C
Rationale: Standard precautions require the use of a mask and eye protection during
procedures that are likely to generate splashes or sprays of blood or body fluids, such as
suctioning.
5. Which documentation entry is the most accurate example of objective data?
A. Patient appears to be in pain
B. Patient states, ‘I feel dizzy when I stand up’
C. Patient is uncooperative during the morning shift
D. Lungs clear to auscultation bilaterally
Answer: D
, Rationale: Objective data is observable and measurable. Clear breath sounds are a physical
assessment finding, whereas statements by the patient are subjective data.
6. A nurse is caring for a patient who is 2 days postoperative following
abdominal surgery. The patient reports a ‘popping’ sensation and the nurse
notes an abdominal wound evisceration. What is the priority nursing action?
A. Apply a dry sterile dressing tightly
B. Cover the protruding organs with sterile gauze moistened with sterile normal saline
C. Push the organs back into the abdominal cavity
D. Position the patient in a high-Fowler’s position
Answer: B
Rationale: Evisceration is a medical emergency. The nurse must cover the exposed tissue
with sterile, saline-moistened dressings to prevent drying and infection while keeping the
patient in low-Fowler’s with knees bent.
7. A patient who is NPO for surgery is complaining of thirst. What is the most
appropriate nursing intervention?
A. Perform frequent oral hygiene
B. Allow the patient to suck on ice chips
C. Provide the patient with a small glass of water
D. Encourage the patient to chew gum
Answer: A
Rationale: Oral hygiene helps moisten the mucous membranes and reduces thirst without
violating NPO status, which is crucial for preventing aspiration during anesthesia.
Week 2 Comprehensive Quiz 2026 |WCU
1. A nurse is caring for a postoperative patient who suddenly develops
restlessness, tachycardia, and a decrease in oxygen saturation. Which action
should the nurse take first?
A. Administer prescribed pain medication
B. Assess airway patency and respiratory rate
C. Notify the surgeon immediately
D. Check the patient’s temperature
Answer: B
Rationale: In postoperative care, the priority is always the ABCs (Airway, Breathing,
Circulation). Restlessness and tachycardia are early signs of hypoxia; assessing the airway
and breathing is the first action.
2. When preparing a sterile field for a dressing change, which action by the
nurse would contaminate the field?
A. Placing sterile items within the 1-inch border of the field
B. Opening the outermost flap away from the body
C. Keeping the sterile field above waist level
D. Holding the sterile drape by the corners
Answer: A
Rationale: The 1-inch (2.5 cm) border around a sterile field is considered contaminated.
Any item placed within this border is no longer sterile.
,3. A patient with a history of deep vein thrombosis (DVT) is scheduled for
surgery. Which preoperative finding should be reported to the surgeon
immediately?
A. A blood pressure of 138/88 mmHg
B. A serum potassium level of 3.8 mEq/L
C. An International Normalized Ratio (INR) of 4.2
D. Anxiety regarding the surgical outcome
Answer: C
Rationale: An INR of 4.2 is significantly elevated (therapeutic range for DVT is usually 2.0-
3.0), indicating a high risk for surgical hemorrhage and must be reported.
4. The nurse is implementing standard precautions. For which patient scenario is
a mask and eye protection required?
A. Emptying a urinary catheter bag
B. Assisting a patient with a bed bath
C. Suctioning a patient with a tracheotomy
D. Measuring a patient’s blood pressure
Answer: C
Rationale: Standard precautions require the use of a mask and eye protection during
procedures that are likely to generate splashes or sprays of blood or body fluids, such as
suctioning.
5. Which documentation entry is the most accurate example of objective data?
A. Patient appears to be in pain
B. Patient states, ‘I feel dizzy when I stand up’
C. Patient is uncooperative during the morning shift
D. Lungs clear to auscultation bilaterally
Answer: D
, Rationale: Objective data is observable and measurable. Clear breath sounds are a physical
assessment finding, whereas statements by the patient are subjective data.
6. A nurse is caring for a patient who is 2 days postoperative following
abdominal surgery. The patient reports a ‘popping’ sensation and the nurse
notes an abdominal wound evisceration. What is the priority nursing action?
A. Apply a dry sterile dressing tightly
B. Cover the protruding organs with sterile gauze moistened with sterile normal saline
C. Push the organs back into the abdominal cavity
D. Position the patient in a high-Fowler’s position
Answer: B
Rationale: Evisceration is a medical emergency. The nurse must cover the exposed tissue
with sterile, saline-moistened dressings to prevent drying and infection while keeping the
patient in low-Fowler’s with knees bent.
7. A patient who is NPO for surgery is complaining of thirst. What is the most
appropriate nursing intervention?
A. Perform frequent oral hygiene
B. Allow the patient to suck on ice chips
C. Provide the patient with a small glass of water
D. Encourage the patient to chew gum
Answer: A
Rationale: Oral hygiene helps moisten the mucous membranes and reduces thirst without
violating NPO status, which is crucial for preventing aspiration during anesthesia.
