NUR 242 MEDICAL SURG EXAM 2025/2026
WITH ACTUAL CORRECT QUESTIONS AND
VERIFIED DETAILED ANSWERS
|CURRENTLY TESTING QUESTIONS AND
SOLUTIONS|ALREADY GRADED
A+|NEWEST|BRAND NEW VERSION
!!|GUARANTEED PASS
A nurse is preparing to give a patient their first dose of IV medications, what must the nurse
consider?
-The nurse must observe the patient closely during the administration AND for a minimum of 5
minutes after the first dose (or longer if clinically indicated).
-The nurse may administer first dose under the direct supervision of MO during medical
emergencies e.g. resuscitation medications such as adenosine
-May "not" administer the first dose of anaesthetic agents or short acting sedative.
-Liaise with MO to administer
A nurse is about to cease IV fluid therapy when they notice that there is still some fluid left in
the bag. What should they do?
All IV fluids are to be discarded into a sink and the amount discarded documented on
the appropriate chart.
List 4 solutions in which additives must not be added
1. Blood
2. Total parenteral nutrition
3. Intralipids
4.Dextrans
The nurse is gives a patient their first dose of IV medications then notices that they start to have
an adverse drug reaction. What is their immediate response?
-Stop the infusion immediately
-Consider MET criteria
,-Inform shift coordinator and MO
-Place red ID band on patient
-Document the event in the progress notes, ensure allergy/adverse reaction is on medication
chart
What is the formula for drops per minute?
Volume (mL) X dropfactor
----------------------------
Time (mins)
What is the formula for mls/hour
Total volume (mls)
---------------------
Time (hours)
List two evidenced based points for managing an IV site?
-Replacing the PIVC after 72 hours reduces the risk of phlebitis and sepsis
-Palpation of the cannula site after cleansing can lead to PIVC associated sepsis
Discuss the PIVAS scoring system
Score 0: Healthy IV site with no signs of phlebitis or any concerns
Score 1: If there is either phlebitis, tenderness or erythema at the IV site. Consider liaising with
MO about rate of infusion, do regular checks on the site and replace dressing if needed
Score 2: Two of the following being present, pain, palpable vein, erythema, swelling and
discharge. Consider liaising with MO to re-site, document all signs and increase observations on
the site.
Score 3: Medium stage of phlebitis
Score 4: Advance stage of phlebitis and start of thrombophlebitis
Score 5: Advance stage of thrombophlebitis
Actions for staged 3-5: Symptoms present are pain along the pathway of canula, erythema,
induration and papable venous cord.
,Remove cannula immediately, consider alternative site, document signs and symptoms, initiate
additional treatment as required, continue to observe and if patient is being discharged arrange
for a GP review
What is the burette formula?
mLs remaining x drop factor
-------------------------------
Drops per min
Define a Central Line
an intravascular
access device or catheter that terminates at or
close to the heart, or in one of the great vessels. A central line may be inserted centrally or
peripherally. The line may be used for infusions, or haemodynamic monitoring
Define Peripherally Inserted Central Catheter
A PICC is a venous catheter that is inserted via the brachial, basilic or cephalic veins and
advanced until the tip is located in the lower one-third of the superior vena cava (SVC), close
to the junction of the SVC and right atrium
When should a CVC/PICC site be assessed?
• Prior to each access/visit
• At dressing change
• At least once per shift
• As clinically indicated
What is the nurse assessing for the site for?
• Signs of local infection at the insertion site (erythema, exudate, tenderness, pain,
redness, swelling,)
• Contact dermatitis may develop in patients allergic to chlorhexidine
Suture/securement device and dressing integrity
• Catheter position (sign of catheter migration)
• Patency of lumens
How often should a positive pressure valve be changed?
Every 7 days
What are some things to consider before discharging your patient home with a PICC?
, • Prior to discharge assess patient's physical and cognitive ability to care for PICC line.
Consider caregiver involvement as appropriate
• Ensure all patients have an out patient appointment to address PICC line care or have a
referral to Silver Chain as appropriate to be managed at home
• Encourage patient to report any changes in their catheter site or any new discomfort to
GP/ Silver Chain. Refer patient to central line information booklet/leaflet for complications
List two evidenced based points relating to PICC and CVC lines
-Aseptic technique should be adhered to at all times to minimise the risk of infection
-Patients must undergo an x-ray after insertion to check it is in the right place
Under what circumstances should a catheter be forced in?
Never
What is normal bladder function?
Normal bladder function involves:
• Voiding at 3-5 hourly intervals
• Nocturia 1-2 times/night
• No urgency
• No dysuria
• No post-void residual
• No incontinence
List 5 factors that impact continence
Risk factors for incontinence include:
• Delirium
• Recurrent urinary tract infection (UTI)
• Age-related changes e.g. atrophic vaginitis
• Obesity
• Adverse pharmaceutical effects
• Psychological disorders
• Endocrine disorders
• Insufficient fluid intake
• Constipation, faecal impaction and faecal incontinence
• Prostate disease
• Neurologic disease e.g. stroke, impaired cognition, spinal cord injury
• Physical limitations
WITH ACTUAL CORRECT QUESTIONS AND
VERIFIED DETAILED ANSWERS
|CURRENTLY TESTING QUESTIONS AND
SOLUTIONS|ALREADY GRADED
A+|NEWEST|BRAND NEW VERSION
!!|GUARANTEED PASS
A nurse is preparing to give a patient their first dose of IV medications, what must the nurse
consider?
-The nurse must observe the patient closely during the administration AND for a minimum of 5
minutes after the first dose (or longer if clinically indicated).
-The nurse may administer first dose under the direct supervision of MO during medical
emergencies e.g. resuscitation medications such as adenosine
-May "not" administer the first dose of anaesthetic agents or short acting sedative.
-Liaise with MO to administer
A nurse is about to cease IV fluid therapy when they notice that there is still some fluid left in
the bag. What should they do?
All IV fluids are to be discarded into a sink and the amount discarded documented on
the appropriate chart.
List 4 solutions in which additives must not be added
1. Blood
2. Total parenteral nutrition
3. Intralipids
4.Dextrans
The nurse is gives a patient their first dose of IV medications then notices that they start to have
an adverse drug reaction. What is their immediate response?
-Stop the infusion immediately
-Consider MET criteria
,-Inform shift coordinator and MO
-Place red ID band on patient
-Document the event in the progress notes, ensure allergy/adverse reaction is on medication
chart
What is the formula for drops per minute?
Volume (mL) X dropfactor
----------------------------
Time (mins)
What is the formula for mls/hour
Total volume (mls)
---------------------
Time (hours)
List two evidenced based points for managing an IV site?
-Replacing the PIVC after 72 hours reduces the risk of phlebitis and sepsis
-Palpation of the cannula site after cleansing can lead to PIVC associated sepsis
Discuss the PIVAS scoring system
Score 0: Healthy IV site with no signs of phlebitis or any concerns
Score 1: If there is either phlebitis, tenderness or erythema at the IV site. Consider liaising with
MO about rate of infusion, do regular checks on the site and replace dressing if needed
Score 2: Two of the following being present, pain, palpable vein, erythema, swelling and
discharge. Consider liaising with MO to re-site, document all signs and increase observations on
the site.
Score 3: Medium stage of phlebitis
Score 4: Advance stage of phlebitis and start of thrombophlebitis
Score 5: Advance stage of thrombophlebitis
Actions for staged 3-5: Symptoms present are pain along the pathway of canula, erythema,
induration and papable venous cord.
,Remove cannula immediately, consider alternative site, document signs and symptoms, initiate
additional treatment as required, continue to observe and if patient is being discharged arrange
for a GP review
What is the burette formula?
mLs remaining x drop factor
-------------------------------
Drops per min
Define a Central Line
an intravascular
access device or catheter that terminates at or
close to the heart, or in one of the great vessels. A central line may be inserted centrally or
peripherally. The line may be used for infusions, or haemodynamic monitoring
Define Peripherally Inserted Central Catheter
A PICC is a venous catheter that is inserted via the brachial, basilic or cephalic veins and
advanced until the tip is located in the lower one-third of the superior vena cava (SVC), close
to the junction of the SVC and right atrium
When should a CVC/PICC site be assessed?
• Prior to each access/visit
• At dressing change
• At least once per shift
• As clinically indicated
What is the nurse assessing for the site for?
• Signs of local infection at the insertion site (erythema, exudate, tenderness, pain,
redness, swelling,)
• Contact dermatitis may develop in patients allergic to chlorhexidine
Suture/securement device and dressing integrity
• Catheter position (sign of catheter migration)
• Patency of lumens
How often should a positive pressure valve be changed?
Every 7 days
What are some things to consider before discharging your patient home with a PICC?
, • Prior to discharge assess patient's physical and cognitive ability to care for PICC line.
Consider caregiver involvement as appropriate
• Ensure all patients have an out patient appointment to address PICC line care or have a
referral to Silver Chain as appropriate to be managed at home
• Encourage patient to report any changes in their catheter site or any new discomfort to
GP/ Silver Chain. Refer patient to central line information booklet/leaflet for complications
List two evidenced based points relating to PICC and CVC lines
-Aseptic technique should be adhered to at all times to minimise the risk of infection
-Patients must undergo an x-ray after insertion to check it is in the right place
Under what circumstances should a catheter be forced in?
Never
What is normal bladder function?
Normal bladder function involves:
• Voiding at 3-5 hourly intervals
• Nocturia 1-2 times/night
• No urgency
• No dysuria
• No post-void residual
• No incontinence
List 5 factors that impact continence
Risk factors for incontinence include:
• Delirium
• Recurrent urinary tract infection (UTI)
• Age-related changes e.g. atrophic vaginitis
• Obesity
• Adverse pharmaceutical effects
• Psychological disorders
• Endocrine disorders
• Insufficient fluid intake
• Constipation, faecal impaction and faecal incontinence
• Prostate disease
• Neurologic disease e.g. stroke, impaired cognition, spinal cord injury
• Physical limitations
