NCLEX- Perioperative Care

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse would include which piece of information in discussions with the client?

ANS: The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

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?

ANS: The surgeon marking the area of the operative procedure

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply.

ANS: 1. Frequent assessment of vital signs 2. Coughing and deep breathing exercises 3. Pain monitoring and medications to relieve pain

The nurse is preparing a client for a right below-the-knee amputation. The nurse anticipates that the client is likely to experience which psychosocial problems in the perioperative period? Select all that apply.

ANS: 1. Grief 2. Anxiety 3. Altered body image

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

ANS: A urinary output of 20 mL/hour

The nurse will be caring for several older adults who will be undergoing general anesthesia. Which older adult will require the closest monitoring for a prolonged effect of anesthesia?

ANS: An older adult with increased amount of fatty tissue

The nurse in the primary 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?

ANS: "These sensations lessen over several months and usually are gone after 1 year."

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?

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

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 would plan to take which action in the initial care of the wound?

ANS: Apply a sterile dressing soaked with normal saline.

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?

ANS: Apply a sterile dressing soaked with sterile normal saline to the wound.

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

ANS: Apply the safety strap 2 inches above the knees.

The nurse is taking care of a client preoperatively. The client is nothing-by-mouth (NPO) and an intermediate and short-acting insulin are scheduled for 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take?

ANS: Call the primary health care provider (PHCP) for clarification.

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?

ANS: Checking the wound site for drainage from the drain

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

ANS: Client complaints of a dry mouth

A client's preoperative vital signs are temperature 98.6°F (37°C) 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 would the nurse take first?

ANS: Compare these values to those recorded previously.

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the nurse observed the client has a patent airway. Which is the next nursing assessment?

ANS: Vital signs

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?

ANS: Informing the surgeon of the situation

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

ANS: Lithotomy

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 would the nurse take first?

ANS: Lower the head of the bed slowly until the dizziness is relieved.

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?

ANS: Notify the registered nurse.

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?

ANS: Oxygen saturation 95% to 100%; blood pressure 120/80 to 130/80 mm Hg

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?

ANS: Pain

The nurse monitors a postoperative client who had abdominal surgery for signs of complications. Which signs/symptoms would the nurse determine to be indicative of a potential complication? Select all that apply.

ANS: 1. Increasing restlessness 2. Unrelieved pain despite receiving analgesics

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6°F (37.6°C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions would the nurse take before notifying the registered nurse? Select all tha

ANS: 1. Review vital signs from previous hour. 2. Observe the urinary catheter for patency and flow. 3.Observe the IV site for patency and correct flow rate. 4. Review when the client last received pain medication.

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 primary health care provider has prescribed neomycin sulfate orally for the client. Which is the rationale for prescribing this medication?

ANS: To decrease the bacteria in the bowel

Following a surgical procedure, the nurse applies sequential compression devices to both lower extremities and turns the machine on. The nurse implements this intervention for which purpose?

ANS: To prevent thrombosis formation in the veins

The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL through an indwelling urinary catheter for the last 2 hours. Based on this finding, which would be the nurse's actions at this time? Select all that apply.

ANS: 1. Check the client's overall intake and output record. 2. Gather data about the urinary catheter and check for patency.

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions would the nurse take in the care of the drain? Select all that apply.

ANS: 1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours.

The nurse is preparing a client for surgery. Which would be components of the plan of care? Select all that apply.

ANS: 1. Instruct the client not to swallow water with oral hygiene on the morning of surgery. 2. Document that any medications the client was instructed to take before surgery are given.

After abdominal surgery, a client experiences an evisceration. Which client statement supports this diagnosis?

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

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 questions would assist the nurse in the collection of data regarding the client's problem? Select all that apply.

ANS: 1. "What have you been eating and drinking since the surgery?" 2. "Have you been experiencing any urge to move your bowels?" 3. "What kind and how often have you been taking medications for pain?"

The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery later in the day. When asking the client whether the client has taken any scheduled or over-the-counter medications in the past 24 hours, which statements would concern the nurse? Select all that apply.

ANS: 1. "Yes, I take a full-strength aspirin every day." 2. "I have taken my medication for my blood pressure this morning."

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 actions would the nurse take to deal with this event? Select all that apply.

ANS: 1. Apply a sterile dressing soaked with normal saline to the wound. 2. Notify the registered nurse (RN) and primary health care provider (PHCP) at once.

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?

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

The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How would the nurse initially address the client's concerns?

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

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

ANS: Assess patency of the airway.

The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are: temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem?

ANS: Pneumonia

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

ANS: Semi-Fowler's

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 would the nurse take? Select all that apply.

ANS: 1. Notify the registered nurse immediately. 2. Document the client's complaint with the exact times. 3. Prepare the client for wound closure by notifying surgery department. 4. Instruct the client to remain quiet and reassure the situation is being taken care of.

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 with the client regarding preparation for the surgical procedure. Which client statement indicates an understanding of the preoperative instructions?

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

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 the nurse to monitor drainage and perform dressing changes. Which client statement indicates a need for further teaching?

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

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 student response is correct?

ANS: "LR is isotonic to plasma and contains electrolytes"

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

ANS: A patent airway

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 nonreddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 mm3 (7.5 × 109/L). Which interpretation does the nurse make of these findings?

ANS: The incision line is slightly edematous but shows no active signs of infecti

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

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

A client is admitted to the surgical unit postoperatively with a self-suction Jackson-Pratt wound drain in place. The nurse determines the drain is functioning correctly with which observations? Select all that apply.

ANS: 1. The bulb container is fully compressed. 2. Bright red bloody drainage is present in the bulb container.

he nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply.

ANS: 1. The presence of purulent drainage 2. Tender firmness palpable around the incision

The nurse is caring for a postoperative client who is wearing an abdominal binder following abdominal surgery. Which interventions would the nurse include in relationship to prescribed dressing change? Select all that apply.

ANS: 1. Sit up for coughing while splinting the incision. 2. Sit up for coughing while splinting the incision.

A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply.

ANS: 1. Tea 2. Ice cream 3. Cream of tomato soup 4. Cream of wheat cereal

The nurse, caring for a client with a postoperative abdominal wound, observes that the dressing has Montgomery ties in place. The nurse determines this intervention will decrease the risk of which complication?

ANS: Skin irritation surrounding the wound

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse would provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply.

ANS: 1. New floaters 2. Increasing redness in the eye

A client has returned to the nursing unit following abdominal hysterectomy. To gather data on the client's postoperative bleeding, the nurse would implement which interventions? Select all that apply.

ANS: 1. Observing perineal pad drainage 2. Observing the abdominal dressing 3.Rolling the client to one side to view bedding 4.Monitoring output from the Jackson-Pratt drain

The nurse is reinforcing instructions to a client with pneumonia about the use of an incentive spirometer in the postoperative period. The nurse would include which information in discussions with the client? Select all that apply.

ANS: 1. Use the incentive spirometer for 5 to 10 breaths every hour while awake. 2.The best results are achieved when sitting at least halfway or fully upright.

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 actions would the nurse take? Select all that apply.

ANS: 1. Ask how the client feels and inquire about any feelings of dizziness. 2. Review the client record to determine time and type of analgesia last received. 3. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

Which types of nourishment would the nurse include when initiating a prescribed clear liquid diet for a postoperative client who has a gag reflex after surgery under general anesthesia? Select all that apply.

ANS: 1. Coffee 2. Ice chips 3. Beef broth 4. Lemon-flavored gelatin

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse would plan to place the client in which position?

ANS: Supine, with the residual limb supported with pillows

A client has been taking prednisone for 3 years. She is scheduled for abdominal hysterectomy. The nurse plans care realizing that postoperatively the client is at risk for which conditions? Select all that apply.

ANS: 1. Increased risk for dehiscence 2.Increased likelihood of surgical site infection

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 findings would indicate a sign of a potential complication? Select all that apply.

ANS: 1. Increasing restlessness 2. A pulse rate of 108 beats per minute 3. A blood pressure (BP) of 88/58 mm Hg 4.Increasing pain unrelieved by analgesics

The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply.

ANS: 1. Increasing restlessness 2. Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and would be reported to the primary health care provider before the surgery? Select all that apply.

ANS: 1. Is allergic to penicillin 2. Wonders if the surgery could cause incontinence 3. History of deep venous thrombosis in right leg 10 years earlier

The nurse is caring for a client following an abdominal surgery 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 would perform which actions? Select all that apply.

ANS: 1. Ask the client whether he has passed any flatus. 2. Document the finding and continue to check for bowel sounds.

The nurse has admitted a client to the clinical nursing unit following a right mastectomy. Which interventions would be included in the plan of care? Select all that apply.

ANS: 1. Elevate the right arm on one or two pillows. 2. Ensure that no venipunctures or blood pressures (BPs) are done in the right arm.

The nurse is preparing the client for transfer to the operating room (OR) because of an emergency situation. The nurse would take which actions in the care of the client? Select all that apply.

ANS: 1. Ensure that the client has voided. 2. Verify the time that the client last ate or drank. 3. Assist the client by contacting family members the client wants notified.

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

ANS: 1. Presence of bowel sounds 2. Whether the client has passed flatus

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse would include which activities in the nursing care plan for the client on the day of surgery? Select all that apply.

ANS: Have the client void before surgery. Determine that the client has signed the informed consent for the surgical procedure.

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 would the nurse plan to take first?

ANS: Recheck the vital signs in 15 minutes.

The nurse is caring for a postoperative client who has been NPO, and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priority item would the nurse place at the client's bedside?

ANS: Suction equipment