,Jersey College NUR 201 Midterm Exam | Medical-Surgical
Nursing I (2026) Q&A
1. A nurse is conducting a preoperative assessment on a client scheduled for a
cholecystectomy. The client reports a family history of a sibling dying during surgery
due to a sudden high fever. The nurse should prioritize notifying the anesthesiologist
about a potential risk for which condition?
A) Anaphylaxis
B) Sepsis
C) Malignant hyperthermia
D) Disseminated intravascular coagulation (DIC)
Correct Answer: Malignant hyperthermia
Rationale: Malignant hyperthermia is a rare, life-threatening inherited muscle
disorder triggered by certain general anesthetics (e.g., succinylcholine, halothane). A
positive family history is the single most important risk factor, making it crucial to
communicate this to the anesthesia team.
2. A nurse is caring for a client in the post-anesthesia care unit (PACU) who is 1 hour
postoperative. The client's oxygen saturation has dropped from 97% to 89%, and
breath sounds are diminished in the lung bases. What is the most likely cause of this
finding?
A) Pneumothorax
B) Pulmonary embolism
C) Laryngospasm
D) Atelectasis
Correct Answer: Atelectasis
,Rationale: Atelectasis is the most common postoperative respiratory complication,
caused by shallow breathing, mucous plugs, and the effects of anesthesia. This leads
to diminished breath sounds and impaired gas exchange (hypoxemia).
3. The nurse is assessing a client's surgical incision 2 days post-operatively and notes
a separation of the wound edges with the protrusion of internal organs. What is the
nurse's immediate action?
A) Gently attempt to push the organs back into the abdominal cavity.
B) Place the client in a high-Fowler's position.
C) Document the finding and notify the surgeon at the next rounding time.
D) Cover the exposed organs with a sterile saline-soaked dressing.
Correct Answer: Cover the exposed organs with a sterile saline-soaked dressing.
Rationale: This finding is wound evisceration, a surgical emergency. The immediate
priority is to protect the exposed organs from contamination and drying out by
covering them with a non-adherent dressing soaked in sterile saline.
4. A nurse is preparing a client for surgery. The client states, "I'm not sure if I really
want this surgery. I don't understand what they are going to do." The client has
already signed the consent form. What is the nurse's most appropriate action?
A) Explain the surgical procedure to the client in simple terms.
B) Reassure the client that the surgeon is very skilled.
C) Notify the surgeon of the client's statement.
D) Document that the consent form is signed and proceed.
Correct Answer: Notify the surgeon of the client's statement.
, Rationale: Informed consent requires that the provider explains the procedure, risks,
benefits, and alternatives to the patient. The nurse's role is to witness the signature
and clarify information, but if the patient expresses a lack of understanding, the
surgeon must be notified to provide additional explanation.
5. A nurse is assessing a patient's respiratory status. Which finding is considered an
early sign of hypoxia?
A) Cyanosis
B) Bradycardia
C) Restlessness and anxiety
D) Hypotension
Correct Answer: Restlessness and anxiety
Rationale: Restlessness and anxiety are early signs of hypoxia as the body tries to
compensate for decreased oxygen. Cyanosis is a late sign, and bradycardia and
hypotension are signs of advanced hypoxia.
6. A patient has a prolonged clotting time. Which vitamin deficiency is most likely
contributing to this finding?
A) Vitamin A
B) Vitamin K
C) Vitamin D
D) Vitamin E
Correct Answer: Vitamin K
Rationale: Vitamin K is essential for the synthesis of clotting factors in the liver. A
deficiency leads to prolonged clotting times and increased bleeding risk.
Nursing I (2026) Q&A
1. A nurse is conducting a preoperative assessment on a client scheduled for a
cholecystectomy. The client reports a family history of a sibling dying during surgery
due to a sudden high fever. The nurse should prioritize notifying the anesthesiologist
about a potential risk for which condition?
A) Anaphylaxis
B) Sepsis
C) Malignant hyperthermia
D) Disseminated intravascular coagulation (DIC)
Correct Answer: Malignant hyperthermia
Rationale: Malignant hyperthermia is a rare, life-threatening inherited muscle
disorder triggered by certain general anesthetics (e.g., succinylcholine, halothane). A
positive family history is the single most important risk factor, making it crucial to
communicate this to the anesthesia team.
2. A nurse is caring for a client in the post-anesthesia care unit (PACU) who is 1 hour
postoperative. The client's oxygen saturation has dropped from 97% to 89%, and
breath sounds are diminished in the lung bases. What is the most likely cause of this
finding?
A) Pneumothorax
B) Pulmonary embolism
C) Laryngospasm
D) Atelectasis
Correct Answer: Atelectasis
,Rationale: Atelectasis is the most common postoperative respiratory complication,
caused by shallow breathing, mucous plugs, and the effects of anesthesia. This leads
to diminished breath sounds and impaired gas exchange (hypoxemia).
3. The nurse is assessing a client's surgical incision 2 days post-operatively and notes
a separation of the wound edges with the protrusion of internal organs. What is the
nurse's immediate action?
A) Gently attempt to push the organs back into the abdominal cavity.
B) Place the client in a high-Fowler's position.
C) Document the finding and notify the surgeon at the next rounding time.
D) Cover the exposed organs with a sterile saline-soaked dressing.
Correct Answer: Cover the exposed organs with a sterile saline-soaked dressing.
Rationale: This finding is wound evisceration, a surgical emergency. The immediate
priority is to protect the exposed organs from contamination and drying out by
covering them with a non-adherent dressing soaked in sterile saline.
4. A nurse is preparing a client for surgery. The client states, "I'm not sure if I really
want this surgery. I don't understand what they are going to do." The client has
already signed the consent form. What is the nurse's most appropriate action?
A) Explain the surgical procedure to the client in simple terms.
B) Reassure the client that the surgeon is very skilled.
C) Notify the surgeon of the client's statement.
D) Document that the consent form is signed and proceed.
Correct Answer: Notify the surgeon of the client's statement.
, Rationale: Informed consent requires that the provider explains the procedure, risks,
benefits, and alternatives to the patient. The nurse's role is to witness the signature
and clarify information, but if the patient expresses a lack of understanding, the
surgeon must be notified to provide additional explanation.
5. A nurse is assessing a patient's respiratory status. Which finding is considered an
early sign of hypoxia?
A) Cyanosis
B) Bradycardia
C) Restlessness and anxiety
D) Hypotension
Correct Answer: Restlessness and anxiety
Rationale: Restlessness and anxiety are early signs of hypoxia as the body tries to
compensate for decreased oxygen. Cyanosis is a late sign, and bradycardia and
hypotension are signs of advanced hypoxia.
6. A patient has a prolonged clotting time. Which vitamin deficiency is most likely
contributing to this finding?
A) Vitamin A
B) Vitamin K
C) Vitamin D
D) Vitamin E
Correct Answer: Vitamin K
Rationale: Vitamin K is essential for the synthesis of clotting factors in the liver. A
deficiency leads to prolonged clotting times and increased bleeding risk.
