NCLEX: Perioperative Care

Increasing restlessness

The nurse is monitoring the status of the postoperative client. The nurse should become most concerned with which sign(s) that could indicate an evolving complication?

Ensure that the client has voided

The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which action in the care of this client at this time?

Suction equipment

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet for a postoperative client who has had general anesthesia?

"Can you share with me what you've been told about your surgery?"

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

Suction equipment

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Checking the wound site for drainage from the drain

The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?

Apply a sterile dressing soaked with sterile normal saline to the wound

The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?

Apply a sterile dressing soaked with normal saline to the wound

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. Which should be the initial action by the nurse?

Patency of the airway

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?

You are concerned that you don't feel any better after surgery?

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 surgery." Which response by the nurse is most appropriate?

Curl the drain tightly and tape it firmly to the body

A client is admitted to the surgical unit postoperatively with a wound drain in place. Which nursing action should the nurse avoid in the care of the drain?

vital signs

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, Which is the initial nursing statement?

"It felt like something just slit me wide open."

A client who currently underwent abdominal surgery experiences an evisceration. Which statement made by the client supports this diagnosis?

Nerve and muscle damage

During a surgical procedure, the nurse prevents a client's extremities from dangling over the sides of the table, knowing that this action may cause what?

"Lactated Ringer's solution is isotonic to plasma."

Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed? Which is a correct response by the student?

Client complaints of a dry mouth

The nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for side effects related to the administration of this medication. Which should the nurse determine is an expected side effect of this medication?

Have the client void immediately before surgery

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?

Apply a sterile dressing soaked with normal saline

When performing a surgical dressing change of a client's abdominal dressing, the 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 plan to do which action in the initial care of this wound?

Lithotomy

When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction when in which position?

Apply the safety strap 2 inches above the knees

Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?

Pain

The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?

Suction equipment

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?

Oxygen saturation 95% to 100%

The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter?

Ask the client to discuss information known about the planned surgery.

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?

The incision line is slightly edematous but shows no active signs of infection

The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. Which interpretation does the nurse make of these findings?

Elevated on one or two pillows

The nurse has admitted a client to the clinical nursing unit following a right mastectomy. The nurse plans to place the right arm in which position?

Bowel sounds

The nurse is caring for a postoperative client who had a pelvic exenteration. The health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks which before administering the clear liquids?

"These sensations dissipate over several months and usually resolve after 1 year."

The nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client?

Notify the registered nurse Document the client's complaint Instruct the client to remain quiet Prepare the client for wound closure

A client who 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 nursing interventions should the nurse take? Select all that apply

"What have you been eating and drinking since the surgery?"

A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which question would assist the nurse in the collection of data regarding the client's problem?

"I cannot drink or eat anything after midnight on the night before surgery."

A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions to the client regarding preparation for the surgical procedure. Which statement by the client indicates an understanding of the preoperative instructions?

Compare these values to those recorded previously

A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first?

"Yes, I take a full-strength aspirin every day."

The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery. When asking the client whether the client takes over-the-counter medications, which statement should concern the nurse?

Discontinue the aspirin 48 hours before the scheduled surgery

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?

Increasing restlessness

The nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication?

Pneumonia

The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?

"I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."

The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from a nurse to monitor drainage and perform dressing changes. Which statement by the client indicates a need for further teaching?

Anxiety

A client has an intravenous infusion (IV) started before surgery for a right below-the-knee amputation. In addition to the intravenous infusion, blood is drawn and a surgical skin preparation is done. The nurse anticipates that the client is likely to experience which psychosocial problem in the preoperative period?

Increased likelihood of surgical site infection

A client has been taking prednisone for 3 years to treat symptoms of lupus erythematosus. She is scheduled for abdominal hysterectomy because of menorrhagia. The nurse plans care realizing that postoperatively the client is at risk for which condition?

Rolling the client to one side to view bedding

A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client's postoperative bleeding, the nurse would implement which intervention?

Informing the surgeon of the situation

A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?

Continue to monitor the vital signs

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 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed?

A patent airway

The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for what data first?

Apply Montgomery ties

The skin surrounding a postoperative client's abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which is the appropriate nursing action?

The best results are achieved when sitting at least halfway or fully upright

The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client?

Do not sleep on the left side

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse should provide the client with which instruction regarding positioning in the postoperative period?

To decrease the bacteria in the bowel

The nurse is reviewing the preoperative prescriptions of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the health care provider has prescribed neomycin sulfate (Mycifradin) for the client. Which is the rationale for prescribing this medication?

Call the health care provider for clarification

The nurse is taking care of a client preoperatively. The client is NPO and tells the nurse that he takes detemir insulin (Levemir) and aspart insulin (NovoLog) at 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take?

Urinary output of 20 mL/hr

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to carefully monitor which parameter during the next hour?

Notify the registered nurse

The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?

The surgeon marking the area of the operative procedure

The nurse is explaining the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery to a group of nursing students. Which action does site marking involve?

Check the client's overall intake and output record

The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL. Based on this finding, what should be the nurse's first action?

A urinary output of 20 mL/hour

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?

Review the results of the preoperative laboratory studies

The nurse is preparing a client for surgery. Which would be a component of the plan of care?

Sit up for coughing while splinting the incision

The nurse reinforces preoperative teaching to a client who will wear an abdominal binder postoperatively following abdominal surgery. Which instruction should the nurse reinforce in the preoperative teaching plan?

Document the finding and continue to check for bowel sounds

The nurse is caring for a client following an abdominal hysterectomy performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse should perform which action?

Secure the drain by curling or folding it and taping it firmly to the body

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?

The surgeon marking the area of the operative procedure

The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action?

To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the sit

The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out?

To allow the surgical team a chance to verbally verify their agreement on the client's name, surgical procedure, and site

The nurse is explaining the concept of time-out in the perioperative area to a group of nursing students. What is the purpose of a time-out?

Lower the head of the bed slowly until the dizziness is relieved

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?

Recheck the vital signs in 15 minutes

The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action should the nurse plan to take first?

Increasing restlessness

The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication?

Semi-Fowler's

The nurse is assisting in caring for a client in transfer from the postanesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling?

Coughing and deep breathing exercises

The nurse is assisting in providing surgical instructions to a preoperative client. Which instruction would be most appropriate to include in the preoperative plan of care?

The presence of purulent drainage

The nurse checks the client's surgical incision for signs of infection. Which is indicative of a potential infection?