NCLEX PERI OP QUESTIONS AND ANSWERS
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
1. Urinary output of 20 mL/hour
2. Temperature of 37.6°C (...
nclex peri op questions and answers the nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit the nurse plans to monitor which parameter
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NCLEX PERI OP QUESTIONS AND
ANSWERS
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical
unit. The nurse plans to monitor which parameter most carefully during the next hour?
1. Urinary output of 20 mL/hour
2. Temperature of 37.6°C (99.6°F)
3. Blood pressure of 100/70 mm Hg
4. Serous drainage on the surgical dressing
The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative
complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to
these techniques?
1. "Use of an incentive spirometer will help prevent pneumonia."
2. "Close monitoring of your oxygen saturation will detect hypoxemia."
3. "Administration of intravenous fluids will prevent or treat fluid imbalance."
4. "Early ambulation and administration of blood thinners will prevent
pulmonary embolism."
The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in
the nursing care plan for the client on the day of surgery?
1. Avoid oral hygiene and rinsing with mouthwash.
2. Verify that the client has not eaten for the last 24 hours.
3. Have the client void immediately before going into surgery.
4. Report immediately any slight increase in blood pressure or pulse.
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of
sedation from opioid analgesics that have been administered. The nurse should take which most appropriate
action in the care of this client?
1. Obtain a court order for the surgery.
2. Have the charge nurse sign the informed consent immediately.
3. Send the client to surgery without the consent form being signed.
4. Obtain a telephone consent from a family member, following agency policy.
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most
likely to stimulate further discussion between the client and the nurse?
1. "If it's any help, everyone is nervous before surgery."
2. "I will be happy to explain the entire surgical procedure to you."
3. "Can you share with me what you've been told about your surgery?"
4. "Let me tell you about the care you'll receive after surgery and the amount of pain
you can anticipate."
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The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse
should include which piece of information in discussions with the client?
1. Inhale as rapidly as possible.
2. Keep a loose seal between the lips and the mouthpiece.
3. After maximum inspiration, hold the breath for 15 seconds and exhale.
4. The best results are achieved when sitting up or with the head of the bed elevated
45 to 90 degrees.
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a
history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional
teaching if the client makes which statement?
1. "Aspirin can cause bleeding after surgery."
2. "Aspirin can cause my ability to clot blood to be abnormal."
3. "I need to continue to take the aspirin until the day of surgery."
4. "I need to check with my health care provider about the need to stop the
aspirin before the scheduled surgery."
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be
interpreted as a normal finding at the surgical site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm, tender skin
The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse
would become most concerned with which sign that could indicate an evolving complication?
1. Increasing restlessness
2. A pulse of 86 beats/minute
3. Blood pressure of 110/70 mm Hg
4. Hypoactive bowel sounds in all 4 quadrants
Rationale:
Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential
complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a
pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal
occurrence in the immediate postoperative period.
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site.
The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which
interventions should the nurse take? Select all that apply.
1. Contact the surgeon.
2. Instruct the client to remain quiet.
3. Prepare the client for wound closure.
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4. Document the findings and actions taken.
5. Place a sterile saline dressing and ice packs over the wound.
6. Place the client in a supine position without a pillow under the head.
Rationale:
Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs
through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client,
and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places
the client in a low Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are
covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for
evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the
findings and actions taken.
A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a
complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should
be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?
1. Hemoglobin, 8.0 g/dL (80 mmol/L)
2. Sodium, 145 mEq/L (145 mmol/L)
3. Serum creatinine, 0.8 mg/dL (70.6 mmol/L)
4. Platelets, 210,000 mm3 (210 × 109/L)
The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to
the surgical unit. The nurse plans to take which action first on arrival of the client?
1. Assess the patency of the airway.
2. Check tubes or drains for patency.
3. Check the dressing to assess for bleeding.
4. Assess the vital signs to compare with preoperative measurements.
The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be
nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should
be given to the client and not withheld?
1. Prednisone
2. Ferrous sulfate
3. Cyclobenzaprine
4. Conjugated estrogen
Rationale:
Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the
ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and
during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous
sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle
relaxant.
Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These
last 3 medications may be withheld before surgery without undue effects on the client.
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