Mod 5 Perioperative Practice Questions from Saunders NCLEX
1. 168. 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: 168. 1 Urinary output of 20
mL/hour
Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an
adult. An output of less than 30 mL for 2 consecutive hours should be reported to
the health care provider. A temperature higher than 37.7 °C (100 °F) or lower than
36.1 °C (97 °F) and a falling systolic blood pressure, lower than 90 mm Hg, are
usually considered reportable immediately. The client's preoperative or baseline
blood pressure is used to make informed postoperative comparisons. Moderate or
light serous drainage from the surgical site is considered normal.
Test-Taking Strategy: Note the strategic word, most. Focus on the subject,
expected postoperative assessment findings. To answer this question correctly,
you must know the normal ranges for temperature, blood pressure, urinary output,
and wound drainage. Note that the urinary output is the only observation that is
not within the normal range.
Review: Postoperative assessment
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Fundamentals of Care—Perioperative
Care Priority Concepts: Clinical Judgment; Perfusion
Reference: Ignatavicius, Workman (2016), p. 262.
2. 169. 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
, Mod 5 Perioperative Practice Questions from Saunders NCLEX
prevent pulmonary embolism.": 169. 1 "Use of an incentive spirometer will
help prevent pneumonia."
Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and
pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes
productive cough, dyspnea, and lung crackles and can be caused by retained
pulmonary secretions. Use of an incentive spirometer helps to prevent pneumonia
and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial
blood. While close monitoring of the oxygen saturation will help to detect
hypoxemia, monitoring is not directly related to coughing and deep-breathing
techniques. Fluid imbalance can be a deficit or excess related to fluid loss or
overload, and surgical clients are often given intravenous fluids to prevent a
deficit; however, this is not related to coughing and deep breathing. Pulmonary
embolus occurs as a result of a blockage of the pulmonary artery that disrupts
blood flow to 1 or more lobes of the lung; this is usually due to clot formation.
Early ambulation and administration of blood thinners helps to prevent this
complication; however, it is not related to coughing and deep-breathing
techniques.
Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the
subject, client instructions related to coughing and deep-breathing techniques.
Also, focus on the data in the question and note the relationship between the
words coughing and deep-breathing in the question and pneumonia in the correct
option.
Review: Postoperative complications
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Fundamentals of Care—Perioperative Care
Priority Concepts: Client Education; Gas Exchange
Reference: Perry, Potter, Ostendorf (2014), pp. 597-599, 893.
3. 170. 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.
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