NUR 242 MEDICAL SURGICAL NURSING EXAM 1
1.A client is scheduled for surgery and cannot read or write. The
surgeon asks the client's spouse to sign the consent form. What is
the nurse's best action?
A) Notify administration to have a legal guardian appointed
B) Allow the spouse to sign as the closest relative
C) Inform the surgeon the client may sign with an "X" in front of two
witnesses
D) Proceed without a signed consent since the client cannot write
Correct Answer: Inform the surgeon the client may sign with an "X" in front
of two witnesses
Rationale: Inability to read or write does not equate to incapacity to consent.
The client can sign with an "X" if witnessed by two people, confirming
comprehension. This preserves client autonomy and meets legal
requirements for informed consent.
2. Which finding is a classic sign of a Stage 3 pressure injury?
A) Non-blanchable erythema over a bony prominence
B) Partial-thickness skin loss with exposed dermis
C) Full-thickness skin loss with damage to subcutaneous tissue
D) Full-thickness tissue loss with exposed bone or muscle
Correct Answer: Full-thickness skin loss with damage to subcutaneous tissue
Rationale: Stage 3 pressure injuries involve full-thickness skin loss extending
into subcutaneous tissue but not through fascia. Stage 1 is non-blanchable
erythema, Stage 2 is partial-thickness, and Stage 4 involves bone or muscle
exposure.
, 3. A nurse witnesses another nurse providing care without proper
hand hygiene and reports this to the charge nurse, who is friends
with the offender and refuses to act. This situation best
exemplifies which ethical concept?
A) Moral distress
B) Ethical dilemma
C) Beneficence
D) Nonmaleficence
Correct Answer: Moral distress
Rationale: Moral distress occurs when a nurse knows the right action but is
constrained from taking it due to institutional barriers. The charge nurse's
refusal creates distress for the reporting nurse, who cannot uphold patient
safety standards.
4. Which type of surgery must be performed without delay due to a
life-threatening condition?
A) Elective surgery
B) Urgent surgery
C) Emergent surgery
D) Optional surgery
Correct Answer: Emergent surgery
Rationale: Emergent surgery is performed immediately to preserve life, limb,
or function. Urgent surgery occurs within 24-30 hours, elective surgery is
scheduled based on preference, and optional surgery is purely personal
choice with no catastrophic outcome from delay.
5. The nurse is caring for a client with cellulitis. Which laboratory
test is most important to evaluate the infection?
A) Serum white blood cell count
, B) Complete metabolic panel
C) Arterial blood gas
D) Serum albumin level
Correct Answer: Serum white blood cell count
Rationale: A complete blood count with differential and wound culture are
key for diagnosing cellulitis. Elevated WBC indicates infection, while wound
culture identifies the causative organism. Other labs do not directly assess
infectious status.
6. When providing patient education for cellulitis, which instruction
is most important for preventing recurrence?
A) Apply warm compresses twice daily
B) Elevate the extremity at least 6 inches above the heart
C) Inspect skin daily for breaks or changes
D) Take antibiotics until symptoms resolve
Correct Answer: Inspect skin daily for breaks or changes
Rationale: Daily skin inspection identifies early signs of breakdown,
preventing infection entry. While elevation and compresses aid healing,
prevention-focused education on daily inspection is paramount for cellulitis
recurrence prevention.
7. A client is receiving a blood transfusion. Which finding indicates a
hemolytic transfusion reaction requiring immediate action?
A) Rash and itching
B) Fever and chills
C) Flank pain and fever
D) Dyspnea and JVD
Correct Answer: Flank pain and fever
, Rationale: Hemolytic reactions occur from ABO incompatibility, presenting
with fever, flank pain, and hemoglobinuria. Immediate transfusion cessation
and KVO saline are required. Rash suggests allergic reaction, while dyspnea
and JVD indicate circulatory overload.
8. A client with a fever is prescribed antipyretics. What is the most
likely nursing diagnosis associated with fever?
A) Hyperthermia
B) Risk for infection
C) Impaired thermoregulation
D) Fluid volume deficit
Correct Answer: Hyperthermia
Rationale: Hyperthermia describes elevated body temperature due to illness
or inflammation. Antipyretics are indicated for fever management. Impaired
thermoregulation relates to environmental or neurologic causes, not
infection-related fever.
9. What is the primary route of transmission for varicella-zoster
virus (shingles) from an infected individual?
A) Contact with vesicular fluid
B) Airborne transmission
C) Droplet transmission
D) Fecal-oral transmission
Correct Answer: Airborne transmission
Rationale: Varicella-zoster (shingles) spreads via airborne transmission from
respiratory droplets or aerosolized vesicular fluid. Airborne precautions are
required for hospitalized patients. Contact precautions alone are insufficient.
1.A client is scheduled for surgery and cannot read or write. The
surgeon asks the client's spouse to sign the consent form. What is
the nurse's best action?
A) Notify administration to have a legal guardian appointed
B) Allow the spouse to sign as the closest relative
C) Inform the surgeon the client may sign with an "X" in front of two
witnesses
D) Proceed without a signed consent since the client cannot write
Correct Answer: Inform the surgeon the client may sign with an "X" in front
of two witnesses
Rationale: Inability to read or write does not equate to incapacity to consent.
The client can sign with an "X" if witnessed by two people, confirming
comprehension. This preserves client autonomy and meets legal
requirements for informed consent.
2. Which finding is a classic sign of a Stage 3 pressure injury?
A) Non-blanchable erythema over a bony prominence
B) Partial-thickness skin loss with exposed dermis
C) Full-thickness skin loss with damage to subcutaneous tissue
D) Full-thickness tissue loss with exposed bone or muscle
Correct Answer: Full-thickness skin loss with damage to subcutaneous tissue
Rationale: Stage 3 pressure injuries involve full-thickness skin loss extending
into subcutaneous tissue but not through fascia. Stage 1 is non-blanchable
erythema, Stage 2 is partial-thickness, and Stage 4 involves bone or muscle
exposure.
, 3. A nurse witnesses another nurse providing care without proper
hand hygiene and reports this to the charge nurse, who is friends
with the offender and refuses to act. This situation best
exemplifies which ethical concept?
A) Moral distress
B) Ethical dilemma
C) Beneficence
D) Nonmaleficence
Correct Answer: Moral distress
Rationale: Moral distress occurs when a nurse knows the right action but is
constrained from taking it due to institutional barriers. The charge nurse's
refusal creates distress for the reporting nurse, who cannot uphold patient
safety standards.
4. Which type of surgery must be performed without delay due to a
life-threatening condition?
A) Elective surgery
B) Urgent surgery
C) Emergent surgery
D) Optional surgery
Correct Answer: Emergent surgery
Rationale: Emergent surgery is performed immediately to preserve life, limb,
or function. Urgent surgery occurs within 24-30 hours, elective surgery is
scheduled based on preference, and optional surgery is purely personal
choice with no catastrophic outcome from delay.
5. The nurse is caring for a client with cellulitis. Which laboratory
test is most important to evaluate the infection?
A) Serum white blood cell count
, B) Complete metabolic panel
C) Arterial blood gas
D) Serum albumin level
Correct Answer: Serum white blood cell count
Rationale: A complete blood count with differential and wound culture are
key for diagnosing cellulitis. Elevated WBC indicates infection, while wound
culture identifies the causative organism. Other labs do not directly assess
infectious status.
6. When providing patient education for cellulitis, which instruction
is most important for preventing recurrence?
A) Apply warm compresses twice daily
B) Elevate the extremity at least 6 inches above the heart
C) Inspect skin daily for breaks or changes
D) Take antibiotics until symptoms resolve
Correct Answer: Inspect skin daily for breaks or changes
Rationale: Daily skin inspection identifies early signs of breakdown,
preventing infection entry. While elevation and compresses aid healing,
prevention-focused education on daily inspection is paramount for cellulitis
recurrence prevention.
7. A client is receiving a blood transfusion. Which finding indicates a
hemolytic transfusion reaction requiring immediate action?
A) Rash and itching
B) Fever and chills
C) Flank pain and fever
D) Dyspnea and JVD
Correct Answer: Flank pain and fever
, Rationale: Hemolytic reactions occur from ABO incompatibility, presenting
with fever, flank pain, and hemoglobinuria. Immediate transfusion cessation
and KVO saline are required. Rash suggests allergic reaction, while dyspnea
and JVD indicate circulatory overload.
8. A client with a fever is prescribed antipyretics. What is the most
likely nursing diagnosis associated with fever?
A) Hyperthermia
B) Risk for infection
C) Impaired thermoregulation
D) Fluid volume deficit
Correct Answer: Hyperthermia
Rationale: Hyperthermia describes elevated body temperature due to illness
or inflammation. Antipyretics are indicated for fever management. Impaired
thermoregulation relates to environmental or neurologic causes, not
infection-related fever.
9. What is the primary route of transmission for varicella-zoster
virus (shingles) from an infected individual?
A) Contact with vesicular fluid
B) Airborne transmission
C) Droplet transmission
D) Fecal-oral transmission
Correct Answer: Airborne transmission
Rationale: Varicella-zoster (shingles) spreads via airborne transmission from
respiratory droplets or aerosolized vesicular fluid. Airborne precautions are
required for hospitalized patients. Contact precautions alone are insufficient.
