NURS 341 UPDATED EXAM SCRIPT QUESTIONS AND
SOLUTIONS GRADED A+
✔✔During the postoperative period, a patient develops hypotension with cold, clammy
skin. The nurse's priority intervention should be:
A. Check recent labs for electrolyte imbalance.
B. Increase IV fluid rate per protocol.
C. Position patient flat with legs elevated.
D. Administer oxygen at 2 L/min via nasal cannula. - ✔✔C. position patient flat with legs
elevated
Hypotension with cold, clammy skin may indicate shock. Elevating the legs helps
increase blood flow to vital organs and improve blood pressure. Other interventions can
follow based on the patient's response.
✔✔A patient in the PACU is showing signs of respiratory distress. Which actions should
the nurse take first? (Select all that apply)
A. Reposition the patient to a lateral position.
B. Assess oxygen saturation and apply oxygen.
C. Increase IV fluids to promote circulation.
D. Perform incentive spirometry exercises. - ✔✔A. reposition the patient to a lateral
position
B. assess oxygen saturation and apply oxygen
The first priority in respiratory distress is to ensure an open airway and optimize
oxygenation. Repositioning to a lateral position helps keep the airway clear, and
applying oxygen supports breathing.
✔✔The nurse is assessing a postoperative patient for potential wound infection. Which
signs would indicate an infection? (Select all that apply)
A. Redness and warmth around the incision.
B. A small amount of clear drainage.
C. Pain localized at the incision site.
D. Temperature of 102°F (38.9°C). - ✔✔A. redness and warmth around the incision
C. pain localized at the incision site
D. temperature of 102
Signs of infection include redness, warmth, localized pain, and fever. Clear drainage is
normal and does not indicate infection.
✔✔Which intervention is essential to prevent deep vein thrombosis (DVT) in a
postoperative patient?
A. Monitor the patient's oxygen saturation regularly.
B. Elevate the patient's legs above heart level.
C. Encourage early ambulation and leg exercises.
,D. Administer pain medication as ordered. - ✔✔C. encourage early ambulation and leg
exercises
Early ambulation and leg exercises promote circulation, which is key to preventing DVT.
Monitoring oxygen, elevating legs, and pain management alone do not directly prevent
DVT.
✔✔What should the nurse teach a patient to help prevent atelectasis postoperatively?
A. Take deep breaths and cough every hour.
B. Use pain medication sparingly.
C. Remain lying flat in bed.
D. Limit fluid intake to prevent aspiration. - ✔✔A. take deep breaths and cough every
hour
Deep breathing and coughing help expand the lungs and prevent atelectasis, which is
the collapse of alveoli. Lying flat, limiting fluids, and sparing pain medication do not
prevent atelectasis.
✔✔The PACU nurse is receiving a report on a patient. Which information is a priority to
include? (Select all that apply)
A. Patient's preoperative anxiety level.
B. Type and amount of anesthesia given.
C. Presence of any drains or tubes.
D. Baseline capillary refill. - ✔✔B. type and amount of anesthesia given
C. presence of any drains or tubes
The type and amount of anesthesia and presence of drains or tubes are essential for
the PACU nurse to monitor recovery and detect complications. Preoperative anxiety and
baseline capillary refill are less critical in the immediate postoperative report.
✔✔Which of the following should the nurse consider before an X-ray?
A. Check if the patient is allergic to shellfish
B. Determine if the patient is pregnant
C. Encourage fluids to flush the contrast
D. Assess for history of bleeding disorders - ✔✔B. determine if the patient is pregnant
Pregnancy must be considered before an X-ray due to radiation risks to the fetus.
Shellfish allergies, fluids, and bleeding disorders are not standard concerns for plain X-
rays.
✔✔A nurse is preparing a patient for a CT scan with contrast. Which pre-procedure
action is essential? (Select all that apply)
A. Check for allergies to iodine or shellfish
B. Ensure the patient is NPO
C. Assess for claustrophobia
, D. Review kidney function tests - ✔✔A. check for allergies to iodine or shellfish
B. ensure the patient is NPO
D. review kidney function tests
For a CT scan with contrast, it's essential to check for allergies to iodine or shellfish
(contrast allergy risk), ensure the patient is NPO (prevents aspiration), and review
kidney function to ensure safe contrast excretion. Claustrophobia assessment is more
relevant to MRIs.
✔✔Which statement by the patient undergoing an MRI would require further education?
A. "I need to lie completely still during the scan."
B. "I removed my jewelry and metal objects."
C. "I can wear my pacemaker during the MRI."
D. "I will take the anxiety medicine if I feel claustrophobic." - ✔✔C. "I can wear my
pacemaker during the MRI."
MRIs use strong magnetic fields, making it unsafe for patients with pacemakers. This
statement shows a misunderstanding, requiring further education. The other statements
correctly prepare the patient.
✔✔A patient with carpal tunnel syndrome is assessed for Tinel's sign. A positive result
would be indicated by:
A. Tingling in the thumb and first three fingers when tapping the wrist
B. Pain upon flexing the wrist
C. Numbness in all five fingers when tapping the wrist
D. Tingling in the little finger only - ✔✔A. Tingling in the thumb and first three fingers
when tapping the wrist
Tinel's sign is positive if tapping over the median nerve produces tingling in the thumb,
index, middle, and ring fingers, indicating carpal tunnel syndrome.
✔✔Which of the following interventions are appropriate for a patient with a suspected
sprain? (Select all that apply)
A. Rest the injured area
B. Apply a warm compress immediately
C. Elevate the injured limb above heart level
D. Compress the injury with an elastic bandage - ✔✔A. rest the injured area
C. elevate the injured limb above heart level
D. compress the injury with an elastic bandage
For a sprain, rest, elevation, and compression help reduce swelling and promote
healing. Warm compresses are avoided initially; ice is preferred in the acute phase.
✔✔A patient is diagnosed with osteomyelitis. Which of the following would be included
in their care plan?
SOLUTIONS GRADED A+
✔✔During the postoperative period, a patient develops hypotension with cold, clammy
skin. The nurse's priority intervention should be:
A. Check recent labs for electrolyte imbalance.
B. Increase IV fluid rate per protocol.
C. Position patient flat with legs elevated.
D. Administer oxygen at 2 L/min via nasal cannula. - ✔✔C. position patient flat with legs
elevated
Hypotension with cold, clammy skin may indicate shock. Elevating the legs helps
increase blood flow to vital organs and improve blood pressure. Other interventions can
follow based on the patient's response.
✔✔A patient in the PACU is showing signs of respiratory distress. Which actions should
the nurse take first? (Select all that apply)
A. Reposition the patient to a lateral position.
B. Assess oxygen saturation and apply oxygen.
C. Increase IV fluids to promote circulation.
D. Perform incentive spirometry exercises. - ✔✔A. reposition the patient to a lateral
position
B. assess oxygen saturation and apply oxygen
The first priority in respiratory distress is to ensure an open airway and optimize
oxygenation. Repositioning to a lateral position helps keep the airway clear, and
applying oxygen supports breathing.
✔✔The nurse is assessing a postoperative patient for potential wound infection. Which
signs would indicate an infection? (Select all that apply)
A. Redness and warmth around the incision.
B. A small amount of clear drainage.
C. Pain localized at the incision site.
D. Temperature of 102°F (38.9°C). - ✔✔A. redness and warmth around the incision
C. pain localized at the incision site
D. temperature of 102
Signs of infection include redness, warmth, localized pain, and fever. Clear drainage is
normal and does not indicate infection.
✔✔Which intervention is essential to prevent deep vein thrombosis (DVT) in a
postoperative patient?
A. Monitor the patient's oxygen saturation regularly.
B. Elevate the patient's legs above heart level.
C. Encourage early ambulation and leg exercises.
,D. Administer pain medication as ordered. - ✔✔C. encourage early ambulation and leg
exercises
Early ambulation and leg exercises promote circulation, which is key to preventing DVT.
Monitoring oxygen, elevating legs, and pain management alone do not directly prevent
DVT.
✔✔What should the nurse teach a patient to help prevent atelectasis postoperatively?
A. Take deep breaths and cough every hour.
B. Use pain medication sparingly.
C. Remain lying flat in bed.
D. Limit fluid intake to prevent aspiration. - ✔✔A. take deep breaths and cough every
hour
Deep breathing and coughing help expand the lungs and prevent atelectasis, which is
the collapse of alveoli. Lying flat, limiting fluids, and sparing pain medication do not
prevent atelectasis.
✔✔The PACU nurse is receiving a report on a patient. Which information is a priority to
include? (Select all that apply)
A. Patient's preoperative anxiety level.
B. Type and amount of anesthesia given.
C. Presence of any drains or tubes.
D. Baseline capillary refill. - ✔✔B. type and amount of anesthesia given
C. presence of any drains or tubes
The type and amount of anesthesia and presence of drains or tubes are essential for
the PACU nurse to monitor recovery and detect complications. Preoperative anxiety and
baseline capillary refill are less critical in the immediate postoperative report.
✔✔Which of the following should the nurse consider before an X-ray?
A. Check if the patient is allergic to shellfish
B. Determine if the patient is pregnant
C. Encourage fluids to flush the contrast
D. Assess for history of bleeding disorders - ✔✔B. determine if the patient is pregnant
Pregnancy must be considered before an X-ray due to radiation risks to the fetus.
Shellfish allergies, fluids, and bleeding disorders are not standard concerns for plain X-
rays.
✔✔A nurse is preparing a patient for a CT scan with contrast. Which pre-procedure
action is essential? (Select all that apply)
A. Check for allergies to iodine or shellfish
B. Ensure the patient is NPO
C. Assess for claustrophobia
, D. Review kidney function tests - ✔✔A. check for allergies to iodine or shellfish
B. ensure the patient is NPO
D. review kidney function tests
For a CT scan with contrast, it's essential to check for allergies to iodine or shellfish
(contrast allergy risk), ensure the patient is NPO (prevents aspiration), and review
kidney function to ensure safe contrast excretion. Claustrophobia assessment is more
relevant to MRIs.
✔✔Which statement by the patient undergoing an MRI would require further education?
A. "I need to lie completely still during the scan."
B. "I removed my jewelry and metal objects."
C. "I can wear my pacemaker during the MRI."
D. "I will take the anxiety medicine if I feel claustrophobic." - ✔✔C. "I can wear my
pacemaker during the MRI."
MRIs use strong magnetic fields, making it unsafe for patients with pacemakers. This
statement shows a misunderstanding, requiring further education. The other statements
correctly prepare the patient.
✔✔A patient with carpal tunnel syndrome is assessed for Tinel's sign. A positive result
would be indicated by:
A. Tingling in the thumb and first three fingers when tapping the wrist
B. Pain upon flexing the wrist
C. Numbness in all five fingers when tapping the wrist
D. Tingling in the little finger only - ✔✔A. Tingling in the thumb and first three fingers
when tapping the wrist
Tinel's sign is positive if tapping over the median nerve produces tingling in the thumb,
index, middle, and ring fingers, indicating carpal tunnel syndrome.
✔✔Which of the following interventions are appropriate for a patient with a suspected
sprain? (Select all that apply)
A. Rest the injured area
B. Apply a warm compress immediately
C. Elevate the injured limb above heart level
D. Compress the injury with an elastic bandage - ✔✔A. rest the injured area
C. elevate the injured limb above heart level
D. compress the injury with an elastic bandage
For a sprain, rest, elevation, and compression help reduce swelling and promote
healing. Warm compresses are avoided initially; ice is preferred in the acute phase.
✔✔A patient is diagnosed with osteomyelitis. Which of the following would be included
in their care plan?
