NUR242 / NUR 242 Exam 1: Medical-
Surgical Nursing Concepts |
Questions and Verified Answers
🛡️ Safety, Infection Control, & Fundamentals (Questions 1-25)
Question 1:
A nurse is assigned to care for a client with a history of generalized tonic-clonic
seizures. Which safety measure should the nurse implement first?
A) Keep a tongue blade at the bedside table.
B) Ensure working suction equipment and oxygen are at the bedside.
C) Set the bed to its highest position to easily access the client.
D) Restrain all four extremities to prevent the client from falling out of bed.
Answer: B
Rationale: Seizure precautions dictate that working suction equipment and oxygen flow
meters must be set up at the bedside to maintain airway patency during or after a
seizure. Padded side rails should be up. Objects should never be placed in a client's
mouth (ruling out A). The bed must be kept in the lowest position to prevent falls (ruling
out C). Restraints are strictly contraindicated during a seizure (ruling out D).
Question 2:
A nurse is preparing to enter the room of a client diagnosed with pulmonary
tuberculosis. Which personal protective equipment (PPE) is required?
A) Surgical mask and sterile gloves
B) Gown, gloves, and a face shield
C) N95 respirator mask
D) Regular procedural mask and shoe covers
Answer: C
Rationale: Pulmonary tuberculosis is transmitted via small-particle aerosols that remain
suspended in the air, requiring Airborne Precautions. The nurse must wear a fit-tested
N95 respirator or a powered air-purifying respirator (PAPR) before entering. A standard
surgical or procedural mask does not filter out airborne particles.
,Question 3:
An assistive personnel (AP) tells the nurse that a client's garbage can has caught fire.
Applying the RACE mnemonic, which action must the nurse take first?
A) Pull the fire alarm lever at the nursing station.
B) Grab a fire extinguisher and aim at the base of the fire.
C) Remove the client from the room to a safe area.
D) Close all doors and windows in the immediate area.
Answer: C
Rationale: The RACE acronym stands for Rescue, Alarm, Confine, Extinguish. The
absolute first priority in any fire situation is to rescue and remove any clients or
individuals in immediate danger to a safe location.
Question 4:
A nurse is caring for an older adult client who is at high risk for falls. Which intervention
is most effective for preventing a fall while maintaining autonomy?
A) Applying a vest restraint while the client sits in a wheelchair.
B) Keeping all four side rails raised at all times.
C) Utilizing a bed or chair exit safety monitoring device.
D) Requesting a prescription for a sedative medication at bedtime.
Answer: C
Rationale: A bed or chair exit alarm alerts staff when a client attempts to get up without
assistance, minimizing fall risk without restricting physical mobility. Vest restraints, four
side rails, and chemical sedatives are restrictive interventions that can increase
agitation, muscle weakness, and the risk of severe injury.
Question 5:
A nurse is discharging a client who has a prescription for a home oxygen concentrator.
Which instruction should the nurse include in the safety teaching?
A) It is safe to use petroleum jelly to lubricate dry nasal passages.
B) Ensure the oxygen tubing is at least 30 feet long to allow free movement.
C) Keep the oxygen delivery system at least 10 feet away from open flames.
D) Increase the oxygen flow rate if you feel short of breath without calling the provider.
Answer: C
Rationale: Oxygen supports combustion, making open flames (like gas stoves, candles,
or smoking) highly dangerous. Devices should be kept at least 10 feet away. Petroleum
jelly is oil-based and flammable; water-soluble lubricants should be used instead (ruling
out A). Tubing over 50 feet can drop pressure, but 30 feet can be a tripping hazard if not
,managed; regardless, C is the definitive safety mandate. Clients must never adjust
prescribed oxygen flow rates independently (ruling out D).
Question 6:
A nurse is changing the linens of a client who has a draining wound infected with
Methicillin-Resistant Staphylococcus aureus (MRSA). Which precautions must the
nurse follow?
A) Standard precautions only
B) Airborne precautions
C) Droplet precautions
D) Contact precautions
Answer: D
Rationale: MRSA in a wound is transmitted via direct or indirect contact with the client or
their contaminated environment. Contact precautions require the nurse to wear a gown
and gloves when handling items in the client's room.
Question 7:
A nurse is reviewing the laboratory results of a client with a chronic wound and notes a
low serum prealbumin level. What does this finding indicate?
A) Acute systemic infection
B) High risk for fluid volume overload
C) Malnutrition and impaired wound healing
D) Decreased oxygen-carrying capacity
Answer: C
Rationale: Serum prealbumin is a sensitive indicators of recent nutritional status
because of its short half-life (about 2 days). Low prealbumin indicates protein-calorie
malnutrition, which directly impairs tissue healing and synthesis.
Question 8:
A nurse is caring for a client with bacterial meningitis. Which type of transmission-based
precaution should the nurse implement?
A) Contact
B) Droplet
C) Airborne
D) Protective environment
, Answer: B
Rationale: Neisseria meningitidis is transmitted through large droplets expelled through
coughing, sneezing, or talking. Droplet precautions require a surgical mask when
working within 3 to 6 feet of the client.
Question 10:
A nurse prepares to perform a sterile wound dressing change. Which action breaks
sterile technique?
A) Opening the topmost flap of the sterile kit away from the body.
B) Dropping a sterile gauze pad into the sterile field from 6 inches above.
C) Keeping the sterile gloved hands above the level of the waist.
D) Turning around to grab extra tape from a counter behind the sterile field.
Answer: D
Rationale: Turning your back on a sterile field or allowing it to fall out of your direct line
of vision breaks sterile technique, as contamination could occur unobserved. All sterile
items must remain in sight and above waist level.
Question 11:
A client asks the nurse why they need a pneumococcal vaccine if they already received
an influenza vaccine this year. What is the nurse's best response?
A) "The influenza vaccine prevents all respiratory infections, but this is a booster."
B) "The influenza vaccine protects against viruses, while the pneumococcal vaccine
protects against specific bacteria."
C) "You only need the pneumococcal vaccine if you develop signs of pneumonia."
D) "Both vaccines protect against the exact same organism, but they are given at
different times."
Answer: B
Rationale: Influenza is caused by viral strains, whereas pneumonia is frequently caused
by bacterial strains like Streptococcus pneumoniae. The vaccines target entirely
different pathogens. Vaccines are primary prevention tools given before illness occurs
(ruling out C).
Question 12:
A nurse is preparing to insert an indwelling urinary catheter. Which action is essential to
prevent a catheter-associated urinary tract infection (CAUTI)?
Surgical Nursing Concepts |
Questions and Verified Answers
🛡️ Safety, Infection Control, & Fundamentals (Questions 1-25)
Question 1:
A nurse is assigned to care for a client with a history of generalized tonic-clonic
seizures. Which safety measure should the nurse implement first?
A) Keep a tongue blade at the bedside table.
B) Ensure working suction equipment and oxygen are at the bedside.
C) Set the bed to its highest position to easily access the client.
D) Restrain all four extremities to prevent the client from falling out of bed.
Answer: B
Rationale: Seizure precautions dictate that working suction equipment and oxygen flow
meters must be set up at the bedside to maintain airway patency during or after a
seizure. Padded side rails should be up. Objects should never be placed in a client's
mouth (ruling out A). The bed must be kept in the lowest position to prevent falls (ruling
out C). Restraints are strictly contraindicated during a seizure (ruling out D).
Question 2:
A nurse is preparing to enter the room of a client diagnosed with pulmonary
tuberculosis. Which personal protective equipment (PPE) is required?
A) Surgical mask and sterile gloves
B) Gown, gloves, and a face shield
C) N95 respirator mask
D) Regular procedural mask and shoe covers
Answer: C
Rationale: Pulmonary tuberculosis is transmitted via small-particle aerosols that remain
suspended in the air, requiring Airborne Precautions. The nurse must wear a fit-tested
N95 respirator or a powered air-purifying respirator (PAPR) before entering. A standard
surgical or procedural mask does not filter out airborne particles.
,Question 3:
An assistive personnel (AP) tells the nurse that a client's garbage can has caught fire.
Applying the RACE mnemonic, which action must the nurse take first?
A) Pull the fire alarm lever at the nursing station.
B) Grab a fire extinguisher and aim at the base of the fire.
C) Remove the client from the room to a safe area.
D) Close all doors and windows in the immediate area.
Answer: C
Rationale: The RACE acronym stands for Rescue, Alarm, Confine, Extinguish. The
absolute first priority in any fire situation is to rescue and remove any clients or
individuals in immediate danger to a safe location.
Question 4:
A nurse is caring for an older adult client who is at high risk for falls. Which intervention
is most effective for preventing a fall while maintaining autonomy?
A) Applying a vest restraint while the client sits in a wheelchair.
B) Keeping all four side rails raised at all times.
C) Utilizing a bed or chair exit safety monitoring device.
D) Requesting a prescription for a sedative medication at bedtime.
Answer: C
Rationale: A bed or chair exit alarm alerts staff when a client attempts to get up without
assistance, minimizing fall risk without restricting physical mobility. Vest restraints, four
side rails, and chemical sedatives are restrictive interventions that can increase
agitation, muscle weakness, and the risk of severe injury.
Question 5:
A nurse is discharging a client who has a prescription for a home oxygen concentrator.
Which instruction should the nurse include in the safety teaching?
A) It is safe to use petroleum jelly to lubricate dry nasal passages.
B) Ensure the oxygen tubing is at least 30 feet long to allow free movement.
C) Keep the oxygen delivery system at least 10 feet away from open flames.
D) Increase the oxygen flow rate if you feel short of breath without calling the provider.
Answer: C
Rationale: Oxygen supports combustion, making open flames (like gas stoves, candles,
or smoking) highly dangerous. Devices should be kept at least 10 feet away. Petroleum
jelly is oil-based and flammable; water-soluble lubricants should be used instead (ruling
out A). Tubing over 50 feet can drop pressure, but 30 feet can be a tripping hazard if not
,managed; regardless, C is the definitive safety mandate. Clients must never adjust
prescribed oxygen flow rates independently (ruling out D).
Question 6:
A nurse is changing the linens of a client who has a draining wound infected with
Methicillin-Resistant Staphylococcus aureus (MRSA). Which precautions must the
nurse follow?
A) Standard precautions only
B) Airborne precautions
C) Droplet precautions
D) Contact precautions
Answer: D
Rationale: MRSA in a wound is transmitted via direct or indirect contact with the client or
their contaminated environment. Contact precautions require the nurse to wear a gown
and gloves when handling items in the client's room.
Question 7:
A nurse is reviewing the laboratory results of a client with a chronic wound and notes a
low serum prealbumin level. What does this finding indicate?
A) Acute systemic infection
B) High risk for fluid volume overload
C) Malnutrition and impaired wound healing
D) Decreased oxygen-carrying capacity
Answer: C
Rationale: Serum prealbumin is a sensitive indicators of recent nutritional status
because of its short half-life (about 2 days). Low prealbumin indicates protein-calorie
malnutrition, which directly impairs tissue healing and synthesis.
Question 8:
A nurse is caring for a client with bacterial meningitis. Which type of transmission-based
precaution should the nurse implement?
A) Contact
B) Droplet
C) Airborne
D) Protective environment
, Answer: B
Rationale: Neisseria meningitidis is transmitted through large droplets expelled through
coughing, sneezing, or talking. Droplet precautions require a surgical mask when
working within 3 to 6 feet of the client.
Question 10:
A nurse prepares to perform a sterile wound dressing change. Which action breaks
sterile technique?
A) Opening the topmost flap of the sterile kit away from the body.
B) Dropping a sterile gauze pad into the sterile field from 6 inches above.
C) Keeping the sterile gloved hands above the level of the waist.
D) Turning around to grab extra tape from a counter behind the sterile field.
Answer: D
Rationale: Turning your back on a sterile field or allowing it to fall out of your direct line
of vision breaks sterile technique, as contamination could occur unobserved. All sterile
items must remain in sight and above waist level.
Question 11:
A client asks the nurse why they need a pneumococcal vaccine if they already received
an influenza vaccine this year. What is the nurse's best response?
A) "The influenza vaccine prevents all respiratory infections, but this is a booster."
B) "The influenza vaccine protects against viruses, while the pneumococcal vaccine
protects against specific bacteria."
C) "You only need the pneumococcal vaccine if you develop signs of pneumonia."
D) "Both vaccines protect against the exact same organism, but they are given at
different times."
Answer: B
Rationale: Influenza is caused by viral strains, whereas pneumonia is frequently caused
by bacterial strains like Streptococcus pneumoniae. The vaccines target entirely
different pathogens. Vaccines are primary prevention tools given before illness occurs
(ruling out C).
Question 12:
A nurse is preparing to insert an indwelling urinary catheter. Which action is essential to
prevent a catheter-associated urinary tract infection (CAUTI)?
