NCLEX PRACTICE QUESTION BASED ON PERIOPERATIVE NURSING CARE Part 7

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  • PREOPERATIVE CARE:
    • Obtaining informed consent
    • Nutrition: NPO
    • Elimination: If client having intestinal and abdominal surgery, an enema, laxative prescribed for the day or night before surgery.
    • Surgical site: clean with mild antiseptic or antibacterial soap
    • Preoperative client teaching:
      • About what to expect postoperatively
      • Notify nurse if client experiences any pain postoperatively
      • Demonstrate the use of the PCA patient-controlled analgesia pump if prescribed
      • deep breathing and coughing techniques
      • Incentive spirometry
      • Leg and foot exercises
      • Splinting the incision
    • Psychosocial preparation
    • Preoperative checklist
      • Wearing identification bracelet
      • Assess for allergies
      • Follow agency policies
      • history and physical examination completed
      • lab tests are documented
      • Remove accessories such as jewelry, makeup, dentures, hairpins, nail polish
      • vital signs monitor and document
    • Arrival in the operative room
      • Verification of the client and the surgical operative site is critical
  • POSTOPERATIVE CARE:
    • Management of a client after surgery to prevent complications, promote healing of the surgical incision and to return the client in healthy state.
    • Assess respiratory system
    • Assess circulatory system
    • Assess musculoskeletal system
    • Neurological system: Level of consciousness
    • Temperature control
    • Integumentary system
    • Fluid and electrolyte balance
    • Gastrointestinal system
    • Renal system
    • Pain management
  • POSTOPERATIVE COMPLICATIONS INCLUDING:
    • Pneumonia: inflammation of alveoli
    • Atelectasis: collapsed or airless state of the lung that may be result of airway obstruction caused by the accumulated secretions or failure of client to deep breath (may occur 1 to 2 days after surgery)
    • Hypoxemia: Inadequate concentration of the oxygen in arterial blood due to shallow breathing from the effects of anesthesia or medications
    • Pulmonary embolism: an embolus blocking the pulmonary artery and disrupting blood flow to 1 or more lobes of the lungs
    • Hemorrhage
    • Shock: loss of circulatory fluid volume which caused by hemorrhage
    • Thrombophlebitis: inflammation of a vein often accompanied by the clot formation
    • Urinary retention: involuntary accumulation of urine in the bladder as a result of loss of muscle tone
    • Constipation: abnormal infrequent passage of stool
    • Paralytic ileus: failure of the appropriate forward movement of the bowel contents
    • Wound infection: caused by the poor aseptic technique.
    • Wound dehiscence: separation of the wound edges at the suture lines; it usually occurs 6-10 days after surgery
    • Wound evisceration: protrusion of the internal organs through an incision; it usually occurs 6-8 days after surgery. It is an emergency.

PRACTICE QUESTIONS:

  1. The nurse has just reassessed the condition of a post-operative 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. Urinary output of 20 mL/hr
    2. Temperature of 37.6 degree C
    3. Blood pressure of 100/70 mmHg
    4. Serous drainage on the surgical dressing
  2. The nurse is teaching a client about coughing and deep breathing techniques to prevent postoperative complications. Which statement is most appropriate for nurse to make to the client at this time as it relates to these techniques?
    1. Use of an incentive spirometer will help prevent pneumonia
    2. Close monitoring of your oxygen saturation will detect hypoxemia
    3. Administration of intravenous fluids will prevent or treat fluid imbalance
    4. Early ambulation and administration of blood thinners will prevent pulmonary embolism
  3. The nurse is creating 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 blood pressure or pulse
  4. A client with a 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 started
    4. Obtain a telephone consent from a family member, following agency policy
  5. 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?
    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 have been told about your surgery
    4. Let me tell you about the care you will receive after surgery and the amount of pain you can anticipate
  6. 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 clients?
    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.
  7. 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 determined 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 doctor about the need to stop the aspirin before the scheduled surgery
  8. The 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
  9. The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become the most concerned with which sign that could indicate an evolving complication?
    1. Increasing restlessness
    2. A pulse of 86 beats per minute
    3. Blood pressure of 110/70 mmHg
    4. Hypoactive bowel sounds in all 4 quadrants
  10. 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 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 ice packs over the wound
    6. Place the client in a supine position without a pillow under the head.
  11. 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 laboratory result should be reported to the surgeon’s office by the nurse, knowing that it could cause surgery to be postponed?
    1. Hemoglobin 8.0g/dL
    2. Sodium145mEq/L
    3. serum cretinine0.8mg/dL
    4. Platelets 210000 cells/mm3
  12. The nurse receives a telephone call from the post anesthesia 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 vitals to compare with preoperative measurements.
  13. The nurse is reviewing a surgeon’s prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld?
    1. Prednisone
    2. Ferrous sulphate
    3. Cyclobenzaprine
    4. Conjugated estrogen

ANSWERS

  1. 1
  2. 1
  3. 3
  4. 4
  5. 3
  6. 4
  7. 3
  8. 2
  9. 1
  10. 1,2,3,4
  11. 1
  12. 1
  13. 1

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