Saunders Comprehensive Review for the NCLEX-RN Exam Pre-op, Intra-op, Post-op

A postoperative client asks a nurse why it is so important to deep-breathe and cough after surgery. In formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative can lead to: 1. Pneumonia 2. Fluid imbalance 3. Pulmonary edema 4. Carbon dioxide retention

1. 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. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary edema usually results from failure of the left side of the heart and can be caused by medications or fluid overload. Carbon dioxide retention results from an inability to exhale carbon dioxide in conditions such as chronic obstructive pulmonary disease. Test-Taking Strategy: Focus on the relationship between the words "deep-breathe and cough" in the question and "pneumonia" is the correct option. Review the common postoperative complications if you had difficulty with this question.

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 of the following laboratory results should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Sodium, 141 mEq/L 2. Hemoglobin, 8.0 g/dL 3. Platelets, 210,000/mm3 4. Serum creatinine, 0.8 mg/dL

2. Hemoglobin, 8.0 g/dL Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon. Test-Taking Strategy: Focus on the subject , an abnormal laboratory result that needs to be reported. Use knowledge of the normal laboratory values to assist in answering correctly. The hemoglobin value is the only incorrect laboratory finding. Review these laboratory values if you had difficulty answering this question.

A nurse is developing a plan of care for a preoperative client who has a latex allergy. Which intervention should be included in the plan? 1. Avoid using medications from glass ampules. 2. Avoid using IV tubing that is made of polyvinyl chloride.. 3. Use medications that are from ampules with rubber stoppers. 4. Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure.

4. Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure. Rationale: If a client has a latex allergy, a cloth barrier should be applied to his or her arm under a blood pressure cuff to prevent skin contact with the cuff. Medications from glass ampules are safe to use, and medications from ampules with rubber stoppers are unsafe to use. Latex-safe intravenous tubing made of polyvinyl chloride should be used for a client with a latex allergy. Additionally, agency procedures should be followed for a client with a latex allergy; usually, a latex allergy cart containing latex-free supplies is kept in the client's room. Test-Taking Strategy: Focus on the subject of the question, the latex allergy. Recalling the causes of a latex allergy will direct you easily to option 4. Review nursing interventions for the client with a latex allergy if you had difficulty with this question.

A nurse is developing a list of home care instructions for a client being discharged after a laparoscopic cholecystectomy. Which of the following instructions would be least appropriate to include in the postoperative discharge plan of care? 1. Wound care 2. Follow-up care 3. Activity restrictions 4. Deep-breathing exercises

4. Deep-breathing exercises Rationale: The type of planning and instruction required varies with each individual and type of surgery. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Deep-breathing exercises are taught in the postoperative period. Test-Taking Strategy: Note the strategy words "least appropriate". Options 1, 2, and 3 are comparative or alike and refer to information that needs to be taught postoperatively. Option 4 refers to information that should be taught preoperatively. Review the client education points related to discharge teaching preoperatively and postoperatively if you had difficulty with this question.

A nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to do which of the following first on arrival of the client? 1. Assess the patency of the airway? 2. Check tubes or trains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements.

1. Assess the patency of the airway? Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established. Test-Taking Strategy: Note the strategic word first. Use the principles of prioritization when answering this question. Use the ABCs—airway , breathing , and circulation . Ensuring airway patency is the first action to be taken, directing you to the correct option. Review the initial care of the post-operative client if you had difficulty with this question.

A nurse is developing a plan of care for a client scheduled for surgery. Then nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Have the client void immediately before surgery. 2. Avoid oral hygiene and rinsing with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Report immediately any slight increase in blood pressure or pulse.

1. Have the client void immediately before surgery. Rationale: The nurse would assist the client to void 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 6 to 8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety. Test-Taking Strategy: Read each option carefully. Eliminate option 4 because of the words "immediately" and "slight". Eliminate option 3, knowing that the client should be NPO for 6 to 8 hours before surgery. There is no useful reason for option 2; in fact, oral hygiene may make the client feel more comfortable. Review general preoperative care if you had difficulty with this question.

A preoperative client expresses anxiety to a 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."

3. "Can you share with me what you've been told about your surgery?" Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety (option 2). Option 4 avoids the client's anxiety and is focuses on postoperative care. Test-Taking Strategy: Note that the client expresses anxiety. Use knowledge of therapeutic communication techniques . Note that the question contains the strategic words "most likely" and also note the words "stimulate further discussion". Also use the steps of the nursing process . The correct option addresses assessment and is the only therapeutic response. If this question was difficult, review the fundamental principles of therapeutic communication.

An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent: 1. An increase in pulse rate. 2. A drop in blood pressure. 3. Nerve and muscle damage. 4. Muscle fatigue in the extremities.

3. Nerve and muscle damage. Rationale: The client's extremities should not be allowed to dangle over the sides of the table because this may impair circulation to the local area or cause nerve and muscle damage. Part of the operating room nurse's role is to ensure that the safety needs of the client are met, which includes proper positioning. Test-Taking Strategy: Use knowledge regarding the basic principles related to positioning. Recall the client is anesthetized will direct you to option 3. Review the nurse's role during surgery if you had difficulty with this question.

A nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which of the following signs that could indicate an evolving complication? 1. Increasing restlessness 2. A negative Homans' sign 3. Hypoactive bowel sounds in all four quadrants 4. Blood pressure of 110/70 mm Hg and a pulse of 86 beats/min

1. Increasing restlessness 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 four quadrants are a normal occurrence, as is a negative Homans' sign (A positive Homans' sign may indicate thrombophlebitis). Test-Taking Strategy: Use the process of elimination and note the strategic word, "most". Focus on the subject , "a manifestation of an evolving complication". Eliminate each of the incorrect options because they are comparable or alike and are normal expected findings. If you had difficulty with this question, review the normal expected postoperative findings and the signs and symptoms of postoperative complications.

A nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time? 1. Ensure the client has voided. 2. Administer all the daily medication. 3. Practice postoperative breathing exercises. 4. Verify that the client has not eaten for the last 24 hours.

1. Ensure the client has voided. The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medication just before sending a client to the operating room. Rather, the physician writes a specific order outlining which medications may be given with a sip of water. The time of transfer to the operating room is nnot the time to practice breathing exercises. This should have been doned earlier. The client has nothing by mouth for 6 to 8 hours before surgery, not 24 hours. Test-Taking Strategy: Note that the question contains the strategic words "at this time". This tells you that you must prioritize your answer according to a time line. With this in mind, eliminate options 2 and 4 first because they are incorrect. Choos correctly between the remaining options by knowing that the client must empty his or her bladder or by knowing that the client is likely to be anxious at this time, making it inappropriate to practice breathing exercises. Revie preoperative nursing intervetiions if you had difficulty with this question.

A nurse is reviewing a physician's order sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the physician to clarify whether which of the following medications should be given to the client and not withheld? 1. Ferrous sulfate 2. Prednisone (Deltasone) 3. Cycloenzaprine (Flexeril) 4. Conjugated estrogen (Premarin)

2. Prednisone (Deltasone) 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. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client. Test-Taking Strategy: Use the process of elimination and knowledge about medications that may have special implications for the surgical client. Focus on the subject, the medication that should be administered in the preoperative period. Remember that when stress is severe, corticosteroids are essential to life. Review the effects of corticosteroids if you had difficulty with this question.

A 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 of the following parameters most carefully during the next hour? 1. Urinary output of 20 mL/hr 2. Temperature of 37.6 C (99.6 F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical drainage

1. Urinary output of 20 mL/hr Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for each of 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: To answer this question correctly, you must know the normal ranges for temperature, blood pressure, urinary output, and wound drainage. Through the process of elimination, you then can determine that the urinary output is the only observation that is not within the normal range. Review these basic postoperative assessment findings if you had difficulty with this question.

A 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

2. Serous drainage Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk. Test-taking strategy: Use the process of elimination, noting the strategy words normal finding. Recalling the signs of a wound infection and noting these strategy words will direct you to option 2. Review the signs of a wound infection if you had difficulty with this question.

When performing a surgical dressing change of a client's abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should do which of the following in the initial care of this wound? 1. Leave the incision open to the air to dry the area. 2. Irrigate the wound and apply a sterile dry dressing. 3. Apply a sterile dressing soaked with normal saline. 4. Apply a sterile dressing soaked in providone-iodine (Betadine).

3. Apply a sterile dressing soaked with normal saline. Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. Dehiscence usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining. The client should be positioned to prevent further stress on the wound (semi-Fowler's). Sterile dressings soaked with sterile normal saline should be used to cover the wound. The nurse must notify the physician after applying the initial dressing to the wound. Options 1, 2, and 4 are incorrect. Test-taking strategy: Use the process of elimination. Eliminate option 1 first because this action would dry the wound and also present a risk of infection to the underlying tissues. Eliminate options 2 and 4 next because a dry dressing and a dressing soaked with providone-iodine will irritate the exposed body tissues. Review initial nursing care when dehiscence or evisceration occurs if you had difficulty with this question.

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse avoid in the care of the drain? 1. Check the drain for patency. 2. Observe for bright red bloody drainage. 3. Curl the drain tightly and tape it firmly to the body. 4. Maintain aseptic technique when emptying the drain.

3. Curl the drain tightly and tape it firmly to the body. Rationale: A postoperative drain should not be curled tightly or obstructed in any way. This could prevent the drain from functioning properly. The nurse should check the tube or drain for patency to provide an exit for the fluid or blood to promote healing. The nurse must use aseptic technique for emptying the drainage container or changing the dressing to avoid contamination of the wound. The nurse should monitor the drainage characteristics. Usually, the drainage from the wound is pale, red, and watery. Active bleeding will be bright red. Test-Taking Strategy: Note the strategy word "avoid". Remember that surgical drains need to remain patent so that accumulated secretions can escape from the wound bed. If you had difficulty with this question, review nursing care for the client with a surgical drain.

A nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse plans to continue with postoperative assessment activities: 1. Every hour for 2 hours, and then every 4 hours as needed. 2. Every 30 minutes for the first hour, every hour for 2 hours, and then every 4 hours as needed. 3. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed. 4. Every 5 minutes for the first half-hour, every 15 minutes for 2 hours, every 30 minutes for 4 hours, and then every hour as needed.

3. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed. Rationale: When the postoperative client arrives from the postanesthesia care unit, the nurse performs an initial assessment. Common time frames for continuing postoperative assessment activities are every 15 minutes the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed. However, agency policies should always be followed. Options 1 and 2 identify time frames that are too infrequent and that will not provide adequate assessment of the postoperative client. Option 4 identifies close time frames that are unnecessary. Test-Taking Strategy: Eliminate option 4 first because the time frames are so close. By the time that the nurse completed the assessment, the 5 minutes would have lapsed and the nurse would immediately have to perform the assessment again. This is unnecessary and unreasonable. Eliminate options 1 and 2 because they identify time frames that are too infrequent and will not provide adequate assessment of the postoperative client. Review postoperative assessment procedures if you had difficulty with this question.

A nurse is monitoring a postoperative client after abdominal surgery for signs of complications. The nurse assesses the client for the presence of Homans' sign and determines that this sign is positive if which of the following is noted? 1. Incisional pain 2. Absent bowel sounds 3. Pain with dorsiflexion of the foot 4. Crackles on auscultation of the lungs

3. Pain with dorsiflexion of the foot Rationale: To elicit Homans' sign, the nurse would dorsiflex the client's foot and assess the client for pain in the calf area. If pain is present, a positive Homans' sign is present, which is an indication of thrombophlebitis. Incisional pain is an expected occurrence after abdominal surgery. Absent bowel sounds may occur in the immediate postoperative period. Crackles on auscultation of the lungs may indicate a respiratory complication. Test-Taking Strategy: Use knowledge of the significance of a positive Homans' sign. Recalling that a positive Homans' sign indicates thrombophlebitis will direct you to option 3. Review this assessment technique if you had difficulty with this question.

A 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 acetylsaliclic acid (aspirin). Then nurse determines that the client needs additional teaching if the client states: 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to discontinue the aspirin 48 hours before the scheduled surgery." 4. "I need to continue to take the aspirin until the day of surgery."

4. "I need to continue to take the aspirin until the day of surgery." Rationale: 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. Options 1, 2, and 4 are accurate client statements. Test-Taking Strategy: Note the strategic words "needs additional teaching". These words indicate a negative event query and that you need to select the incorrect client statement. Eliminate options 1 and 2 first because they are comparable or alike . From the remaining options, recalling that aspirin has properties that can alter the clotting mechanism will direct you to the correct option. If you had difficulty with this question, review medications that affect the client preparing for surgery.

A client with a perforated 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 appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Send the client to surgery without the consent form being signed. 3. Have the hospital chaplain sign the informed consent immediately. 4. Obtain a telephone consent from a family member, following agency policy.

4. Obtain a telephone consent from a family member, following agency policy. Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but in this case it is not an emergency. Options 1 and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed. Test-Taking Strategy: Note the strategic words "most appropriate". Focus on the data in the question. Eliminate 1 and 3 first. Option 1 will delay necessary surgery and option 3 is inappropriate. Select the correct option over option 2 because it is the most appropriate of the options presented and it is legally acceptable to obtain a telephone permission from a family member if it is witnessed by two persons. Review the implications surrounding informed consent if you had difficulty with this question.

A nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussion 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.

4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly. Test-Taking Strategy: Visualize the procedure for using the incentive spirometer. Options 1, 2, and 3 are incorrect steps regarding incentive spirometer use. The breath should be held for five seconds before exhaling slowly.