NUR 242 Exam 1 Medical-Surgical Nursing Concepts |
Comprehensive Review Questions and Correct Answers &
Rationales | New Update 2026-2027 - Galen
1. Which of the following best describes the primary purpose of the Rapid
Response Team (RRT) in a medical-surgical unit?
A) To provide routine daily assessments for all patients on the unit
B) To bring critical care expertise to the bedside of a deteriorating patient
C) To manage the unit's staffing ratios and assignment of nurses
D) To oversee the hospital's discharge planning process
Correct Answer: To bring critical care expertise to the bedside of a deteriorating
patient
Rationale: The Rapid Response Team (RRT) is a multidisciplinary team that
responds to early signs of clinical deterioration to prevent cardiac arrest and
improve patient outcomes. They do not perform routine assessments, manage
staffing, or handle discharge planning. The RRT is a key component of a culture of
safety.
2. What is the primary function of the SBAR communication tool in nursing
handoff?
A) To document patient vital signs in the medical record
B) To provide a structured framework for conveying critical information during
handoff
C) To order medications from the pharmacy
D) To schedule patient appointments
Correct Answer: To provide a structured framework for conveying critical
information during handoff
Rationale: SBAR stands for Situation, Background, Assessment, and
Recommendation. It is a standardized communication tool used to convey critical
information during handoffs, especially in urgent situations. It improves patient
,safety and reduces communication errors. It does not document vital signs, order
medications, or schedule appointments.
3. According to the exam blueprint, which professional nursing concept is the
major priority for medical-surgical nurses?
A) Patient and staff safety
B) Financial efficiency of care delivery
C) Completion of all assigned tasks
D) Adherence to hospital policy without exception
Correct Answer: Patient and staff safety
Rationale: The exam blueprint notes that patient and staff safety is the major
priority for professional nurses. This includes preventing errors, reducing falls, and
maintaining a safe environment. While efficiency and policy adherence are
important, safety is the overriding priority.
4. Which finding is most consistent with a positive Chvostek's sign?
A) Facial twitching when the facial nerve is tapped
B) Carpal spasm when a blood pressure cuff is inflated
C) Absence of deep tendon reflexes
D) Muscle rigidity and hyperthermia
Correct Answer: Facial twitching when the facial nerve is tapped
Rationale: Chvostek's sign is assessed by tapping the facial nerve (in front of the
ear) and observing for facial muscle twitching. It indicates hypocalcemia and
increased neuromuscular excitability. Trousseau's sign (carpal spasm) also
indicates hypocalcemia. Absence of reflexes suggests hypermagnesemia.
5. What is the primary purpose of administering Trousseau's sign assessment?
A) To evaluate the patient's gag reflex
B) To assess for hypocalcemia by inflating a blood pressure cuff
C) To determine the presence of meningeal irritation
D) To evaluate cranial nerve function
Correct Answer: To assess for hypocalcemia by inflating a blood pressure cuff
,Rationale: Trousseau's sign is assessed by inflating a blood pressure cuff above the
patient's systolic pressure for 2 to 5 minutes. If carpal spasm occurs, it indicates
hypocalcemia. This is a standard assessment for patients at risk for low calcium,
such as after thyroidectomy.
6. Which finding is most consistent with hypokalemia?
A) Muscle weakness with flattened T waves on ECG
B) Peaked T waves on ECG
C) Hyperactive deep tendon reflexes
D) Hypertension and tachycardia
Correct Answer: Muscle weakness with flattened T waves on ECG
Rationale: Hypokalemia impairs neuromuscular and cardiac conduction, causing
muscle weakness, fatigue, and ECG changes such as flattened T waves and
prominent U waves. Peaked T waves are seen in hyperkalemia. Hyperactive
reflexes are associated with hypocalcemia.
7. What is the primary treatment for severe hyperkalemia?
A) Administering potassium supplements
B) Administering calcium gluconate, insulin with glucose, and sodium bicarbonate
C) Restricting fluid intake
D) Administering loop diuretics
Correct Answer: Administering calcium gluconate, insulin with glucose, and
sodium bicarbonate
Rationale: Treatment for hyperkalemia includes calcium gluconate to stabilize
cardiac membranes, insulin with glucose to shift potassium into cells, and sodium
bicarbonate to correct acidosis. Potassium supplements would worsen
hyperkalemia. Restricting fluids and administering loop diuretics are not first-line
treatments.
8. Which finding is most consistent with hypernatremia?
A) Intense thirst and dry mucous membranes
B) Crackles and bounding pulses
, C) Bradycardia and hypotension
D) Polyuria and dilute urine
Correct Answer: Intense thirst and dry mucous membranes
Rationale: Hypernatremia reflects a water deficit relative to sodium, stimulating
thirst and causing dehydration signs such as dry mucous membranes. Crackles and
bounding pulses suggest fluid volume excess. Polyuria and dilute urine are seen in
diabetes insipidus.
9. What is the primary purpose of administering 0.9% sodium chloride
(normal saline)?
A) To provide free water to dehydrated cells
B) To expand intravascular volume and replace extracellular fluid
C) To lower serum potassium levels
D) To induce diuresis in a patient with heart failure
Correct Answer: To expand intravascular volume and replace extracellular fluid
Rationale: 0.9% sodium chloride is an isotonic crystalloid used for extracellular
volume replacement. It remains in the extracellular space and supports
intravascular volume expansion. It does not provide free water (hypotonic fluids
do), lower potassium, or induce diuresis.
10.Which IV fluid should the nurse question for a patient with increased
intracranial pressure?
A) 0.9% sodium chloride
B) Lactated Ringer's solution
C) Hypotonic fluid
D) 5% dextrose in 0.9% sodium chloride
Correct Answer: Hypotonic fluid
Rationale: Hypotonic fluids can shift water into brain cells and worsen cerebral
edema in a patient with increased intracranial pressure. Isotonic fluids such as
0.9% sodium chloride and lactated Ringer's are safer choices. Hypertonic saline
may be used to reduce cerebral edema.
11.Which finding suggests a transfusion reaction?
Comprehensive Review Questions and Correct Answers &
Rationales | New Update 2026-2027 - Galen
1. Which of the following best describes the primary purpose of the Rapid
Response Team (RRT) in a medical-surgical unit?
A) To provide routine daily assessments for all patients on the unit
B) To bring critical care expertise to the bedside of a deteriorating patient
C) To manage the unit's staffing ratios and assignment of nurses
D) To oversee the hospital's discharge planning process
Correct Answer: To bring critical care expertise to the bedside of a deteriorating
patient
Rationale: The Rapid Response Team (RRT) is a multidisciplinary team that
responds to early signs of clinical deterioration to prevent cardiac arrest and
improve patient outcomes. They do not perform routine assessments, manage
staffing, or handle discharge planning. The RRT is a key component of a culture of
safety.
2. What is the primary function of the SBAR communication tool in nursing
handoff?
A) To document patient vital signs in the medical record
B) To provide a structured framework for conveying critical information during
handoff
C) To order medications from the pharmacy
D) To schedule patient appointments
Correct Answer: To provide a structured framework for conveying critical
information during handoff
Rationale: SBAR stands for Situation, Background, Assessment, and
Recommendation. It is a standardized communication tool used to convey critical
information during handoffs, especially in urgent situations. It improves patient
,safety and reduces communication errors. It does not document vital signs, order
medications, or schedule appointments.
3. According to the exam blueprint, which professional nursing concept is the
major priority for medical-surgical nurses?
A) Patient and staff safety
B) Financial efficiency of care delivery
C) Completion of all assigned tasks
D) Adherence to hospital policy without exception
Correct Answer: Patient and staff safety
Rationale: The exam blueprint notes that patient and staff safety is the major
priority for professional nurses. This includes preventing errors, reducing falls, and
maintaining a safe environment. While efficiency and policy adherence are
important, safety is the overriding priority.
4. Which finding is most consistent with a positive Chvostek's sign?
A) Facial twitching when the facial nerve is tapped
B) Carpal spasm when a blood pressure cuff is inflated
C) Absence of deep tendon reflexes
D) Muscle rigidity and hyperthermia
Correct Answer: Facial twitching when the facial nerve is tapped
Rationale: Chvostek's sign is assessed by tapping the facial nerve (in front of the
ear) and observing for facial muscle twitching. It indicates hypocalcemia and
increased neuromuscular excitability. Trousseau's sign (carpal spasm) also
indicates hypocalcemia. Absence of reflexes suggests hypermagnesemia.
5. What is the primary purpose of administering Trousseau's sign assessment?
A) To evaluate the patient's gag reflex
B) To assess for hypocalcemia by inflating a blood pressure cuff
C) To determine the presence of meningeal irritation
D) To evaluate cranial nerve function
Correct Answer: To assess for hypocalcemia by inflating a blood pressure cuff
,Rationale: Trousseau's sign is assessed by inflating a blood pressure cuff above the
patient's systolic pressure for 2 to 5 minutes. If carpal spasm occurs, it indicates
hypocalcemia. This is a standard assessment for patients at risk for low calcium,
such as after thyroidectomy.
6. Which finding is most consistent with hypokalemia?
A) Muscle weakness with flattened T waves on ECG
B) Peaked T waves on ECG
C) Hyperactive deep tendon reflexes
D) Hypertension and tachycardia
Correct Answer: Muscle weakness with flattened T waves on ECG
Rationale: Hypokalemia impairs neuromuscular and cardiac conduction, causing
muscle weakness, fatigue, and ECG changes such as flattened T waves and
prominent U waves. Peaked T waves are seen in hyperkalemia. Hyperactive
reflexes are associated with hypocalcemia.
7. What is the primary treatment for severe hyperkalemia?
A) Administering potassium supplements
B) Administering calcium gluconate, insulin with glucose, and sodium bicarbonate
C) Restricting fluid intake
D) Administering loop diuretics
Correct Answer: Administering calcium gluconate, insulin with glucose, and
sodium bicarbonate
Rationale: Treatment for hyperkalemia includes calcium gluconate to stabilize
cardiac membranes, insulin with glucose to shift potassium into cells, and sodium
bicarbonate to correct acidosis. Potassium supplements would worsen
hyperkalemia. Restricting fluids and administering loop diuretics are not first-line
treatments.
8. Which finding is most consistent with hypernatremia?
A) Intense thirst and dry mucous membranes
B) Crackles and bounding pulses
, C) Bradycardia and hypotension
D) Polyuria and dilute urine
Correct Answer: Intense thirst and dry mucous membranes
Rationale: Hypernatremia reflects a water deficit relative to sodium, stimulating
thirst and causing dehydration signs such as dry mucous membranes. Crackles and
bounding pulses suggest fluid volume excess. Polyuria and dilute urine are seen in
diabetes insipidus.
9. What is the primary purpose of administering 0.9% sodium chloride
(normal saline)?
A) To provide free water to dehydrated cells
B) To expand intravascular volume and replace extracellular fluid
C) To lower serum potassium levels
D) To induce diuresis in a patient with heart failure
Correct Answer: To expand intravascular volume and replace extracellular fluid
Rationale: 0.9% sodium chloride is an isotonic crystalloid used for extracellular
volume replacement. It remains in the extracellular space and supports
intravascular volume expansion. It does not provide free water (hypotonic fluids
do), lower potassium, or induce diuresis.
10.Which IV fluid should the nurse question for a patient with increased
intracranial pressure?
A) 0.9% sodium chloride
B) Lactated Ringer's solution
C) Hypotonic fluid
D) 5% dextrose in 0.9% sodium chloride
Correct Answer: Hypotonic fluid
Rationale: Hypotonic fluids can shift water into brain cells and worsen cerebral
edema in a patient with increased intracranial pressure. Isotonic fluids such as
0.9% sodium chloride and lactated Ringer's are safer choices. Hypertonic saline
may be used to reduce cerebral edema.
11.Which finding suggests a transfusion reaction?
