NUCLEX ACTUAL EXAM 2024-2025
WITH CORRECT DETAILED SOLUTIONS
(100%VERIFIED ANSWERS |GRADED
A+)
A client has arrived in the postoperative unit. What action by the circulating nurse takes
priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report - answers-ANS: D
Hand-offs are a critical time in client care, and poor communication during this time can
lead to serious errors. The postoperative nurse and circulating nurse participate in
hand-off report as the priority. Assessing fluid losses and dressings can be done
together as part of the report. Ensuring the client is warm is a lower priority.
DIF: Applying/Application REF: 257
KEY: Postoperative nursing| communication| hand-off communication| SBAR
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of
Care
The postanesthesia care unit (PACU) charge nurse notes vital signs on four
postoperative clients. Which client should the nurse assess first?
a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respiratory rate of 6 breaths/min
d. Client with a temperature of 96° F (35.6° C) - answers-ANS: C
The respiratory rate is the most critical vital sign for any client who has undergone
general anesthesia or moderate sedation, or has received opioid analgesia. This
respiratory rate is too low and indicates respiratory depression. The nurse should
assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be
within that client's baseline. A pulse of 118 beats/min is slightly fast, which could be due
to several causes, including pain and anxiety. A temperature of 96° F is slightly low and
the client needs to be warmed. But none of these other vital signs take priority over the
respiratory rate.
,DIF: Applying/Application REF: 258
KEY: Postoperative nursing| nursing assessment| sedation| respiratory system
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of
Care
A postoperative nurse is caring for a client whose oxygen saturation dropped from 98%
to 95%. What action by the nurse is most appropriate?
a. Assess other indicators of oxygenation.
b. Call the Rapid Response Team.
c. Notify the anesthesia provider.
d. Prepare to intubate the client. - answers-ANS: A
If a postoperative client's oxygen saturation (SaO2) drops below 95% (or the client's
baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or
more, the nurse should call the Rapid Response Team. Since this is approximately a
3% drop, the nurse should further assess the client. Intubation (if the client is not
intubated already) is not warranted.
Ten hours after surgery, a postoperative client reports that the antiembolism stockings
and sequential compression devices itch and are too hot. The client asks the nurse to
remove them. What response by the nurse is best?
a. "Let me call the surgeon to see if you really need them."
b. "No, you have to use those for 24 hours after surgery."
c. "OK, we can remove them since you are stable now."
d. "To prevent blood clots you need them a few more hours." - answers-ANS: D
According to the Surgical Care Improvement Project (SCIP), any prophylactic
measures to prevent thromboembolic events during surgery are continued for 24 hours
afterward. The nurse should explain this to the client. Calling the surgeon is not
warranted. Simply telling the client he or she has to wear the hose and compression
devices does not educate the client. The nurse should not remove the devices.
DIF: Understanding/Comprehension REF: 260
KEY: Postoperative nursing| Surgical Care Improvement Project (SCIP)| venous
thromboembolism prevention| thromboembolic events| core measures| quality
improvement
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of
Care
, A client had a surgical procedure with spinal anesthesia. The nurse raises the head of
the client's bed. The client's blood pressure changes from 122/78 mm Hg to 102/50 mm
Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Lower the head of the bed.
d. Nothing; this is expected. - answers-ANS: C
A client who had epidural or spinal anesthesia may become hypotensive when the
head of the bed is raised. If this occurs, the nurse should lower the head of the bed to
its original position. The Rapid Response Team is not needed, nor is an increase in IV
rate.
A postoperative client vomited. After cleaning and comforting the client, which action by
the nurse is most important?
a. Allow the client to rest.
b. Auscultate lung sounds.
c. Document the episode.
d. Encourage the client to eat dry toast. - answers-ANS: B
Vomiting after surgery has several complications, including aspiration. The nurse
should listen to the client's lung sounds. The client should be allowed to rest after an
assessment. Documenting is important, but the nurse needs to be able to document
fully, including an assessment. The client should not eat until nausea has subsided.
A postoperative client has just been admitted to the postanesthesia care unit (PACU).
What assessment by the PACU nurse takes priority?
a. Airway
b. Bleeding
c. Breathing
d. Cardiac rhythm - answers-ANS: A
Assessing the airway always takes priority, followed by breathing and circulation.
Bleeding is part of the circulation assessment, as is cardiac rhythm.
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