NCLEX PN - Perioperative Care
the nurse is developing a plan of care for a client who is scheduled for surgery. the nurse should include which activity in the nursing care plan for the client on the day of surgery? A) have the client void immediately before surgery B) avoid oral hygiene and rinsing with moutwash C) verify that the client has not eaten for the last 24 hours D) report immediately any slight increase in blood pressure or pulse
A) have the client void immediately before surgery rationale the nurse should assist the client with voiding immediately before surgery so that the bladder will be empty. oral hygiene is allowed, but the client should not swallow any water. the client usually has a restriction of food and fluids for 8 hours before surgery rather than 24 hours. a slight increase in blood pressure and pulse is common during the peroperative period; this is generally the result of anxiety.
a client arrives to the surgical nursing unit after surgery. what should be the initial nursing action after surgery? A) patency of the airway B) dressing for bleeding C) tubes or drains for patency D) vital signs to compare with preoperative measures
A) patency of the airway rationale if the airway is not patent, immediate measures must be taken for the survival of the client. after checking the client's airway, the nurse would then check the client's vital signs, and this would be followed by checking the dressings, tubes and drains
the nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem? A) pneumonia B) fluid imbalance C) pulmonary edema D) carbon dioxide retention
A) pneumonia rationale the most common postoperative respiratory problems are atelectasis, pneumonia and pulmonary emboli. pneumonia is the inflammation of lung tissue that causes a productive cough, dyspnea, and crackles. fluid imbalance can be a deficit or excess related to fluid loss or overload. pulmonary edema usually results from left-sided heart failure, and it can be caused by medications, fluid overload, and smoke inhalation. carbon dioxide retention results from the inability to exhale carbon dioxide in clients with conditions such as chronic obstructive pulmonary disease
the nurse is monitoring an adult client for postoperative complications. which is most indicative of a potential postoperative complication that requires further observation? A) a urinary output of 20 ml/hr B) a temperature of 37.6 C (99.6 F) C) a blood pressure of 100/70 mmHg D) serous drainage on the surgical dressing
A) urinary output of 20 ml/hr rationale urine output is maintained at a minimum of at least 30 ml/hr for an adult. an output of less than 30 ml/hr for each of 2 consecutive hours should be reported to the surgeon. a temperature more than 37 C (100 F) or less than 36.1 C (97 F) and a falling systolic blood pressure less than 90 mmHg are to be reported. 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
the nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. what should be the initial action by the nurse? A) cover the wound with a Betadine-soaked dressing B) apply a sterile dressing soaked with normal saline to the wound C) leave the incision open to the air to assist with drying the drainage D) clean the wound using aseptic technique and apply a sterile dressing
B) apply a sterile dressing soaked with normal saline to the wound rationale wound dehiscence is the separation of the wound edges at the suture line. signs and symptoms include increased drainage and the appearance of underlying tissue. it usually occurs as a complication 6 to 8 days after surgery. the client should be instructed to remain quiet and avoid coughing or straining, and he or she should be positioned to prevent further stress on the wound. sterile dressings soaked with sterile normal saline should be used to cover the wound the surgeon needs to be notified
the nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. the client's blood pressure (BP) is 100/60 mmHg, the pulse is 90 beats per minute. on the basis of these findings, which nursing action should be performed? A) shake the client gently to arouse B) continue to monitor the vital signs C) call the RN immediatel y D) cover the client with a warm blanket
B) continue to monitor the vital signs rationale a slightly lower-than-normal BP and an increased pulse rate are common after surgery. the level of consciousness can be determined by checking the client's response to light touch and verbal stimuli rather than by shaking the client. warm blankets are applied to maintain the client's body temperature. there is no reason to contact the RN immediately.
the nurse checks the client's surgical incision for signs of infection. which is indicative of a potential infection? A) the presence of serous drainage B) the presence of purulent drainage C) a temperature of 98.8 F (37.1 C) D) the client complaining of feeling cold
B) the presence of purulent drainage rationale signs and symptoms of a wound infection include warm, red, and tender skin around the incision. the client may have fever and chills. purulent material may exit from drains or from separated wound edges. infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3 to 6 days after surgery serous drainage is not indicative of a wound infection. a temperature of 98.8 F is not an abnormal finding in a postoperative client. the fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection
the nurse is caring for a client who is scheduled for surgery. the client is concerned about the surgical procedure. which action should alleviate the client's fears and misconceptions about surgery? A) tell the client that preoperative fear is normal B) explain all nursing care and possible discomfort that may result C) ask the client to discuss information known about the planned surgery D) provide explanations about the procedures involved in the planned surgery
C) ask the client to discuss information known about the planned surgery rationale explanations should begin with the information that the client knows. option A is a block to communication and options B and D may produce additional anxiety in the client.
the nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. the nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). the nurse reports the information to the health care provider and anticipates that the provider will prescribe which? A) discontinue the aspirin immediately B) continue to take the aspirin as prescribed C) discontinue the aspirin 48 hours before the scheduled surgery D) decrease the dose of the aspirin to half of what is normally taken
C) discontinue the aspirin 48 hours before the scheduled surgery rational e anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery. aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. however, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. therefore, the remaining options are incorrect.
the nurse is caring for a postoperative client who has a drain inserted into the surgical wound. which action should the nurse avoid in the care of the drain? A) check the drain for patency B) observe for bright red, blood drainage C) maintain aseptic technique when emptying D) secure the drain by curling or folding it and taping it firmly to the body
D) secure the drain by curling or folding it and taping it firmly to the body rational e aseptic technique must be used when emptying the drainage container or changing the dressing to avoid contamination of the wound. usually drainage from the wound is pale, red, and watery, whereas active bleeding will be bright red in color. the drain should be checked for patency to provide an exit for the fluid or blood to promote healing. the nurse needs to ensure that drainage flows freely and that there are no kinks in the drains. curling or folding the drain prevents the flow of the drainage
the nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. in planning to initiate this diet, which priority item should the nurse place at the client's bedside? A) a straw B) code cart C) blood pressure cuff D) suction equipment
D) suction equipment rationale in a postoperative client, a concern related to initiating a diet is aspiration. initiating postoperative oral fluids may lead to distention and vomiting. suction equipment must be available. a blood pressure cuff may be necessary but is not the priority from the options provided. a code cart is unnecessary. a straw may help the client sip fluids but is not necessary
a client had an aortic valve replacement 2 days ago. this morning, the client tells the nurse, "i don't feel any better than I did before the surgery," which response by the nurse is most appropriate? A) you will feel better in a week or two B) it's only the second day post-op. cheer up C) this is a normal frustration. it'll get better D) you are concerned that you don't feel any better after surgery
D) you are concerned that you don't feel any better after surgery rationale paraphrasing is restating the client's message in the nurse's own words. paraphrasing may be in the form of a question. option D uses the therapeutic communication technique of paraphrasing. the client is frustrated and is searching for understanding. options A, B, and C are inappropriate communication techniques. option A belittles the client's concerns. options B and C offer false reassurance by the nusre
