NCLEX questions: Perioperative Nursing
A client who has 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 1. Contact the surgeon 2. Instruct the client to remain quiet 3. Prepare the client for wound closure 4. Document the findings and actions taken 5. Place a sterile saline dressing and icepacks over the wound 6. Place the client in a prone position without a pillow under the head.
1, 2, 3 ,4 Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low fowlers position and the client is kept quite and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.
The nurse is reviewing a prescription sheet for preoperative client that states that he client must be NPO after midnight. The nurse would telephone the physician to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine (Flexeril) 4. Conjugated estrogen (Premarin)
1. 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. These last few medications may be withheld before surgery without undue effects on the client.
A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? 1. Pneumonia 2. Hypoxemia 3. Fluid imbalance 4. Pulmonary embolism
1. 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 the retention of pulmonary secretions.
The nurse assess 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 is an expected finding at a surgical site. The other options indicate signs of wound infection. Wound infection usually appears 3 to 6 days after surgery.
A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which of the following actions in the care of this client? 1. Obtain a telephone consent from the family member witnessed by two persons. 2. Obtain a court order for the surgery. 3. Send the client to surgery without the consent form being signed. 4. Have the hospital chaplain sign the informed consent immediately.
2 .Obtain a telephone consent from the family member witnessed by two persons. **Rationale: Every effort must 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 emergencies, the client may be unable to sign, and family members may not be available. In this type of situation, the physician is legally permitted to perform surgery without consent. Options 2 and 4 are not appropriate. Additionally, actions that delay treatment in an emergency are not appropriate. Test-Taking Strategy: Note the strategic words "emergency surgery." Eliminate options 2 and 4 first because they are the least reasonable of all the options. Select option 1 over option 3 because it is legally acceptable to obtain telephone permission from a family member if it is witnessed by two persons and is the most appropriate of the options presented. Review the implications surrounding informed consent if you had difficulty with this question.
A preoperative client expresses anxiety to the 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 with 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. 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.
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions 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 For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowlers or high fowlers 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.
A nurse is teaching a client about the use of an incentive spirometer in the postoperative period. The nurse should include which of the following pieces of information in discussions with the client? 1. Keep a loose seal between the lips and the mouthpiece. 2. Inhale as rapidly as possible. 3. After maximum inspiration, hold the breath for 10 seconds and exhale. 4. The best results are achieved when sitting at least halfway or fully upright.
4. The best results are achieved when sitting at least halfway or fully upright. **Rationale: For optimal lung expansion with an incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely while the client inhales slowly with a constant flow through the unit. The breath should be held for 2 to 3 seconds before exhaling slowly. Test-Taking Strategy: Focus on the subject, the procedure for using the incentive spirometer, and visualize this procedure. Options 1, 2, and 3 are incorrect steps for incentive spirometer use. Option 4 is correct. If you had difficulty with this question, review the correct procedure related to the use of an incentive spirometer.
A nurse is monitoring the status of the postoperative client. The nurse would become most concerned with which of the following signs, which could indicate an evolving complication? 1. Blood pressure of 110/70 mm Hg with a pulse of 86 beats per minute 2. Increasing restlessness 3. Hypoactive bowel sounds in all four quadrants 4. A negative Homans' sign
Increasing restlessness **Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a complication such as shock. Hearing hypoactive bowel sounds in all four quadrants is a normal occurrence, as is a negative Homans' sign. (A positive Homans' sign may be indicative of thrombophlebitis.) A blood pressure of 110/70 mm Hg with a pulse of 86 beats per minute is within normal limits. Test-Taking Strategy: Use the process of elimination and focus on the subject, an evolving complication. Eliminate each of the incorrect options because they 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.
The 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 take which action first on arrival of the client? 1. Assess the patency of the airway 2. Check tubes or drains for patency 3. Check the dressing to assess for bleeding 4. Assess the vital signs to compare with preoperative measurements
1. The first action of the nurse is to assess the patency of the airway snd 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 of the dressing and tubes or drains.
The 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 parameter most carefully during the next hour? 1. Urine output of 20ml/hour 2. Temperature of 37.6 C 3. Blood pressure of 114/70 4. Serous drainage on the surgical dressing
1. Urine output should be maintained at a minimum of 30mL/hour for an adult. An output of less than that for each of 2 consecutive hours should be reported to the health care provider.
A nurse is reviewing the physician's order sheet for the preoperative client, which states that the client must be on nothing per mouth (NPO) status after midnight. The nurse would clarify whether which of the following medications should be given to the client and not withheld? 1. Conjugated estrogen (Premarin) 2. Atenolol (Tenormin) 3. Cyclobenzaprine (Flexeril) 4. Ferrous sulfate
2. Atenolol (Tenormin) **Rationale: Atenolol is a ß-blocker. ß-Blockers should not be stopped abruptly, and the physician should be contacted about the administration of this medication prior to surgery. If a ß-blocker is stopped abruptly, the myocardial need for oxygen is increased. Cyclobenzaprine is a skeletal muscle relaxant. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Conjugated estrogen is an estrogen used for hormonal replacement therapy in postmenopausal women. The other three medications may be withheld before surgery without undue effects on the client. Test-Taking Strategy: Knowledge about medications that may have special implications for the surgical client is required to answer this question. Focus on the action and use of the medications presented in the options, and think about their effects on the body. This will direct you to option 2. Review preoperative procedures related to medications if you had difficulty with this question.
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 most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from a family member, following agency policy
4. 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 the client may not be able 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 tin this case it is not an emergency. Agency policies regarding informed consent should always be followed.
A 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 of the following actions should the nurse plan to take first? 1. Recheck the vital signs in 15 minutes. 2. Call the surgeon immediately. 3. Cover the client with a warm blanket. 4. Shake gently to arouse.
1. Recheck the vital signs in 15 minutes. **Rationale: A drop in blood pressure slightly below a client's preoperative baseline reading is common after surgery. The nurse should recheck the vital signs. Warm blankets are applied to maintain the client's body temperature. Level of consciousness can be assessed by the evaluation of the client's response to light touch and verbal stimuli. It is not necessary to contact the surgeon immediately. Test-Taking Strategy: Use principles of priority setting and the ABCs—airway, breathing, and circulation—to answer this question. Note that the strategic word in the question is "first." Checking vital signs takes priority over warming the client and arousing the client. The vital signs are within normal limits following this surgical procedure; therefore, the surgeon does not need to be notified immediately. Review postoperative data collection procedures if you had difficulty with this question.
A client is admitted to the surgical unit postoperatively with a wound drain (Hemovac) in place. Which of the following nursing actions would the nurse avoid in the care of the drain? 1. Check the drain for patency. 2. Curl the drain tightly and tape it firmly to the body. 3. Maintain aseptic technique when emptying. 4. Observe for bright red bloody drainage.
2. Curl the drain tightly and tape it firmly to the body. **Rationale: A postoperative drain should not be curled tightly or obstructed in any other way. This could prevent the drain from functioning properly. The tube or drain should be checked for patency to provide an exit for the fluid and blood to promote healing. Aseptic technique must be used when emptying the drainage container or changing the dressing to avoid contamination of the wound. Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red. Test-Taking Strategy: Read the question carefully, noting the strategic word "avoid." This word indicates a negative event query and asks you to select an option that is an incorrect statement. This will direct you to option 2. The other options are appropriate nursing actions in the care of tubes and drains. If you had difficulty with this question, review nursing care for the client with a surgical drain.
A nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions in the care of this client at this time? 1. Administer all the daily medications. 2. Ensure that the client has voided. 3. Verify that the client has not eaten for the last 24 hours. 4. Practice postoperative breathing exercises.
2. Ensure that the client has voided. **Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just prior to sending a client to the OR. Rather, the physician writes a specific order outlining which medications may be given with a sip of water. The client has nothing by mouth for 8 hours prior to surgery, not 24. The time of transfer to the OR is not the time to practice breathing exercises. This should have been accomplished earlier. Test-Taking Strategy: Note that the question contains the strategic words "at this time." This tells you that you must prioritize your actions according to a time line. With this in mind, eliminate options 1 and 3 first because of the words "all" in option 1 and "24 hours" in option 3. Choose correctly between the remaining two options, either by knowing that the client must empty the bladder or that the client is likely to be anxious at this time, making it inappropriate to practice breathing exercises. Review nursing care for the preoperative client if you had difficulty with this question.
The 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 acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my HCP about the need to stop the aspirin before the scheduled surgery."
3. Anticoagulants altered 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.
The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours 3. Have the client void immediately before going into surgery 4. Report immediately any slight increase in BP or pulse
3. 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 BP and pulse is common during the preoperative period due to anxiety.
A nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to most carefully monitor which of the following parameters during the next hour? 1. Serous drainage on the surgical dressing 2. Blood pressure of 100/70 mm Hg 3. Urinary output of 20 mL/hour 4. Temperature of 99.6° F (37.6° C)
3. Urinary output of 20 mL/hour **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. A temperature above 100°F (37.7° C) or below 97° F (36.1° C) and a falling systolic blood pressure under 90 mm Hg are usually considered reportable at once. 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 can determine that the urinary output is the only observation that is not within the normal range. Review the expected postoperative data collection findings if you had difficulty with this question.
A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following responses by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "I will be happy to explain the entire surgical procedure to you." 2. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate." 3. "If it's any help, everyone is nervous before surgery." 4. "Can you share with me what you've been told about your surgery?"
4. "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 an individualized explanation of care and procedures, the nurse can assist the client in handling fears and providing a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Options 1, 2, and 3 are nontherapeutic responses. Test-Taking Strategy: Note the strategic words "most likely" and "stimulate further discussion." Use of therapeutic communication skills and interviewing techniques will direct you to the correct option. If this question was difficult, review these communication techniques.
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 plan to 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. Apply a povidone-iodine-soaked sterile dressing. 3. Irrigate the wound and apply a dry sterile dressing. 4. Apply a sterile dressing soaked with normal saline.
4. 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 exposure of underlying tissues. It usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client 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 physician must be notified after this initial dressing has been applied to the wound. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first because it would dry the wound and present a risk of infection of underlying tissues. Eliminate options 2 and 3 next because a dry dressing and a dressing soaked with povidone-iodine will irritate the exposed body tissues. Review emergency care when dehiscence or evisceration occurs if you had difficulty with this question.
A client who has undergone preadmission testing, has had blood drawn for serum lab studies, including a complete blood count, coagulation studies and electrolytes and creatine levels. Which lab result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Sodium, 141mEq/L 2. Hemoglobin, 8.0 g/dL 3. Platelets, 210,000/mm3 4. Serum creatine, 0.8 mg/dL
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. Lab work is completed in the preoperative, intraoperative, and postoperative phases as needed Results of blood work are analyzed by nurse as well as the anesthesiologist and surgeon. Interdisciplinary team communicates any concerns regarding abnormalities. Other specifics tests ordered by the HCP.
