NUR 265 Final Exam. This includes all major topics: Perioperative Care, Shock, Sepsis,
Burns, Neurological Disorders, Spinal Cord Injuries, Endocrine Disorders,
Gastrointestinal, Renal, Hematology, Oncology, Respiratory, Cardiovascular, and
Prioritization/Delegation.
Perioperative & Postoperative Care
1. A patient is 4 hours post-op from a total hip replacement. Which finding
requires immediate notification of the surgeon?
A) Pain rated 6/10
B) Heart rate 110 bpm, BP 88/50
C) Urine output 35 mL/hr
D) Temperature 99.6°F (37.6°C)
Answer: B
Tachycardia with hypotension in the immediate post-op period suggests hypovolemia or
hemorrhage until proven otherwise. This requires immediate surgical notification. Urine
output of 35 mL/hr is adequate (>30 mL/hr).
2. A patient received general anesthesia. The nurse's priority in the immediate
post-op period is:
A) Pain management
B) Airway patency
C) Wound assessment
D) Fluid replacement
,Answer: B
Airway is always the first priority in the immediate post-operative period, as anesthesia
can cause airway obstruction and respiratory depression.
3. Which assessment finding indicates malignant hyperthermia?
A) Hypothermia and bradycardia
B) Muscle rigidity and hyperthermia
C) Hypotension and polyuria
D) Respiratory depression and miosis
Answer: B
Malignant hyperthermia is a life-threatening reaction to volatile anesthetics or
succinylcholine, characterized by muscle rigidity, hyperthermia, tachycardia, and
tachypnea.
4. A patient post-op has a Jackson-Pratt drain with 150 mL of bright red blood in 1
hour. What should the nurse do first?
A) Document as normal
B) Empty the drain
C) Notify the provider
D) Increase IV fluids
Answer: C
Output greater than 100 mL/hr of bright red blood from a surgical drain indicates active
hemorrhage. The provider must be notified immediately.
5. A patient post-op from a thyroidectomy reports tingling around the mouth and
muscle twitching. The nurse should prepare to administer:
A) Calcium gluconate
B) Levothyroxine
,C) Potassium chloride
D) Magnesium sulfate
Answer: A
Tetany (tingling, twitching) after thyroidectomy indicates hypocalcemia from accidental
parathyroid injury or removal. IV calcium gluconate is the treatment.
6. Which medication is given to reverse the effects of neuromuscular blockers?
A) Naloxone
B) Neostigmine
C) Flumazenil
D) Protamine sulfate
Answer: B
Neostigmine, an acetylcholinesterase inhibitor, is given with glycopyrrolate to reverse the
effects of non-depolarizing neuromuscular blockers.
7. A patient post-op has an order for enoxaparin (Lovenox). The nurse knows this
is given to:
A) Treat pain
B) Prevent DVT
C) Induce sedation
D) Control nausea
Answer: B
Enoxaparin is a low-molecular-weight heparin (LMWH) used for venous thromboembolism
(VTE) prophylaxis, including deep vein thrombosis (DVT) prevention after surgery.
8. A patient 6 hours post-op has not voided and reports bladder fullness. The
nurse percusses dullness over the bladder. What is the priority action?
, A) Encourage oral fluids
B) Perform a straight catheterization
C) Apply a warm compress to the perineum
D) Document as normal for 6 hours post-op
Answer: B
Bladder distention with inability to void 6 hours post-op indicates urinary retention.
Straight catheterization provides immediate relief and prevents bladder injury.
9. The nurse assesses a patient's surgical incision on post-op day 3. Which finding
requires immediate intervention?
A) Mild erythema at incision edges
B) Temperature 99.2°F (37.3°C)
C) Purulent drainage from incision
D) Pain rated 4/10 at incision site
Answer: C
Purulent (pus-like) drainage indicates wound infection, which requires prompt
intervention. Mild erythema and low-grade fever can be expected inflammatory responses.
10. A patient received epidural anesthesia. Which finding requires immediate
action?
A) Blood pressure 100/70
B) Motor block resolving
C) Respiratory rate 8 breaths/min
D) Pain score 3/10
Answer: C
A respiratory rate of 8 indicates respiratory depression, which can occur from a high spinal
block or opioid-induced respiratory depression. This is life-threatening.
Burns, Neurological Disorders, Spinal Cord Injuries, Endocrine Disorders,
Gastrointestinal, Renal, Hematology, Oncology, Respiratory, Cardiovascular, and
Prioritization/Delegation.
Perioperative & Postoperative Care
1. A patient is 4 hours post-op from a total hip replacement. Which finding
requires immediate notification of the surgeon?
A) Pain rated 6/10
B) Heart rate 110 bpm, BP 88/50
C) Urine output 35 mL/hr
D) Temperature 99.6°F (37.6°C)
Answer: B
Tachycardia with hypotension in the immediate post-op period suggests hypovolemia or
hemorrhage until proven otherwise. This requires immediate surgical notification. Urine
output of 35 mL/hr is adequate (>30 mL/hr).
2. A patient received general anesthesia. The nurse's priority in the immediate
post-op period is:
A) Pain management
B) Airway patency
C) Wound assessment
D) Fluid replacement
,Answer: B
Airway is always the first priority in the immediate post-operative period, as anesthesia
can cause airway obstruction and respiratory depression.
3. Which assessment finding indicates malignant hyperthermia?
A) Hypothermia and bradycardia
B) Muscle rigidity and hyperthermia
C) Hypotension and polyuria
D) Respiratory depression and miosis
Answer: B
Malignant hyperthermia is a life-threatening reaction to volatile anesthetics or
succinylcholine, characterized by muscle rigidity, hyperthermia, tachycardia, and
tachypnea.
4. A patient post-op has a Jackson-Pratt drain with 150 mL of bright red blood in 1
hour. What should the nurse do first?
A) Document as normal
B) Empty the drain
C) Notify the provider
D) Increase IV fluids
Answer: C
Output greater than 100 mL/hr of bright red blood from a surgical drain indicates active
hemorrhage. The provider must be notified immediately.
5. A patient post-op from a thyroidectomy reports tingling around the mouth and
muscle twitching. The nurse should prepare to administer:
A) Calcium gluconate
B) Levothyroxine
,C) Potassium chloride
D) Magnesium sulfate
Answer: A
Tetany (tingling, twitching) after thyroidectomy indicates hypocalcemia from accidental
parathyroid injury or removal. IV calcium gluconate is the treatment.
6. Which medication is given to reverse the effects of neuromuscular blockers?
A) Naloxone
B) Neostigmine
C) Flumazenil
D) Protamine sulfate
Answer: B
Neostigmine, an acetylcholinesterase inhibitor, is given with glycopyrrolate to reverse the
effects of non-depolarizing neuromuscular blockers.
7. A patient post-op has an order for enoxaparin (Lovenox). The nurse knows this
is given to:
A) Treat pain
B) Prevent DVT
C) Induce sedation
D) Control nausea
Answer: B
Enoxaparin is a low-molecular-weight heparin (LMWH) used for venous thromboembolism
(VTE) prophylaxis, including deep vein thrombosis (DVT) prevention after surgery.
8. A patient 6 hours post-op has not voided and reports bladder fullness. The
nurse percusses dullness over the bladder. What is the priority action?
, A) Encourage oral fluids
B) Perform a straight catheterization
C) Apply a warm compress to the perineum
D) Document as normal for 6 hours post-op
Answer: B
Bladder distention with inability to void 6 hours post-op indicates urinary retention.
Straight catheterization provides immediate relief and prevents bladder injury.
9. The nurse assesses a patient's surgical incision on post-op day 3. Which finding
requires immediate intervention?
A) Mild erythema at incision edges
B) Temperature 99.2°F (37.3°C)
C) Purulent drainage from incision
D) Pain rated 4/10 at incision site
Answer: C
Purulent (pus-like) drainage indicates wound infection, which requires prompt
intervention. Mild erythema and low-grade fever can be expected inflammatory responses.
10. A patient received epidural anesthesia. Which finding requires immediate
action?
A) Blood pressure 100/70
B) Motor block resolving
C) Respiratory rate 8 breaths/min
D) Pain score 3/10
Answer: C
A respiratory rate of 8 indicates respiratory depression, which can occur from a high spinal
block or opioid-induced respiratory depression. This is life-threatening.
