NURS PERIOP NCLEX EXAM QUESTIONS WITH ANSWERS 2023 A+ GUARANTEED SUCCESS A+, Exams of Nursing

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ANSWERS 2023 A+ GUARANTEED SUCCESS A+

1.) A patient is now in the recovery room after having vaginal surgery. Due to the positioning of the procedure, you would want to assess for what while the patient is in recovery?* A. Bowel Sounds B. Dysrhythmia C. Homan's Sign D. Hemoglobin Level

The answer is C. Vaginal surgeries require the patient to be in the lithotomy

position. This position can put the patient at risk for a deep vein thrombosis.

Therefore, the nurse would want to check for this by using Homan's Sign.

2.) After surgery your patient is semicomatose with vital signs within normal limits. As the nurse, what position would be best for this patient?* A. Semi-Fowlers B. Prone C. Low-Fowlers D. Side positioning preferably on the left side

The answer is D. Patients who are semi comatose are at risk for aspiration

(due to secretions pooling in the mouth or vomiting which is a common side

effect of sedation). Placing the patient onto their side preferably the left will

help decrease the risk of aspiration and help promote cardiovascular

circulation.

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3.) After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST?* A. Apply warm blankets & continue oxygen as prescribed B. Take the patient's rectal temperature C. Page the doctor for further orders D. Adjust the thermostat in the room

The answer is A. Shivering is an early sign that the patient is starting to

experience hypothermia. Immediately, the nurse would need to control the

shivering by applying warm blankets and continue oxygen. When the patient

starts to experience hypothermia, vital organs are not receiving as much

oxygenated blood due to the vasoconstriction. Therefore, oxygen would

need to be continued. Then the nurse would take the patient's temperature.

4.) The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention?* A. BP 100/ B. 24-hour urine output of 300 ml C. Pain rating of 4 on 1-10 scale D. Temperature of 99.3' F

The answer is B. The nurse needs to watch the patient's urinary output

closely. Urinary output within a 24-hour period should be at least 30 ml/hr.

In this case, the patient is only urinating 12.5 ml/hr.

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which is failure for the bowels to move its contents. The only correct non-

invasive option is to encourage ambulation, maintain NPO status, and

monitor intake & output. Inserting a NG tube or administering IV fluids is

invasive and requires a MD order. Patients with potential paralytic ileus are

to be NPO (nothing by mouth) so encouraging fluid intake is incorrect

7.) What is a potential postoperative concern regarding a patient who has already resumed a solid diet?* A. Failure to pass stool within 12 hours of eating solid foods B. Failure to pass stool within 48 hours of eating solid foods C. Passage of excessive flatus D. Patient reports a decreased appetite

The answer is B. After a patient resumes solid food, they should

have a bowel movement within 48 hours. The patient may be

experiencing constipation and appropriate interventions must be

followed.

8.) A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention?* A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated B. Encourage patient to use the incentive spirometer device 10 times every 1- hours while awake C. Encourage early ambulation and patient to eat meals in beside chair D. Repositioning every 3-4 hours

The answer is D. All options are correct expect for repositioning every 3-

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hours. If the patient is unable to reposition themselves or ambulate, they

must be repositioned every 1 to 2 hours minimally.

9.) When assessing your patient who is post-opt, you notice that the patient's right calf vein feels hard, cord-like, and is tender to the touch. The patient reports it is aching and painful. What would NOT be an appropriate nursing intervention for this patient?* A. Allow the patient to dangle the legs to help increase circulation and alleviate pain B. Instruct the patient to not sit in one position for a long period of time C. Elevate the extremity 30 degrees without allowing any pressure on affected area D. Administer anticoagulants as ordered by MD

The answer is A. All options are correct except for "Allow the patient to

dangle the legs to help increase circulation and alleviate pain". The patient

should NOT dangle the legs because this causes blood to pool in the lower

extremities which will put the patient at risk for another blood clot

formation.

10.) A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would?* A. Continue to monitor the patient B. Notify the MD C. Obtain an EKG D. Check the patient's blood glucose

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B. The patient blows on the mouthpiece rapidly. C. The patient uses the incentive spirometry once a day D. The patient rapidly inhales on the devices and exhales

The answer is A. All of the options are wrong expect for "The patient inhales

slowly on the device and maintains the flow indicator between 600 to 900

level". The other options do not demonstrate how to properly use the

incentive spirometry.

13.) As the nurse you are getting the patient ready for surgery. You are completing the preoperative checklist. Which of the following is not part of the preoperative checklist?* A. Assess for allergies B. Conducting the Time Out C. Informed consent is signed D. Ensuring that the history and physical examination has been completed

The answer is B. The time out is conducted by the OR nurse prior to

surgery. All of the other options are conducted by the nurse getting the

patient ready for surgery.

14.) You are completing the history on a patient who is scheduled to have surgery. What health history increases the risk for surgery for the patient?* A. Urinary Tract infections B. History of Premature Ventricle Beats C. Abuse of street drugs

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D. Hyperthyroidism 15.) As a nurse, which statement is incorrect regarding an informed consent signed by a patient?* A. The nurse is responsible for obtaining the consent for surgery B. Patients under 18 years of age may need a parent or legal guardian to sign a consent form C. The nurse can witness the client signing the consent form D. It is the nurse's responsibility to ensure the patient has been educated by the physician about the procedure before informed consent is obtained

The answer is A. All statements are correct except that it's the nurse's

responsibility for obtaining the consent for surgery. It is the surgeon's

responsibility

16.) 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? A. Urine output of 20ml/hour B. Temperature of 37.6 C C. Blood pressure of 114/ D. Serous drainage on the surgical dressing The answer is A.Urine output should be maintained at a minimum of 30mL/hour for

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18.) 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? A. Avoid oral hygiene and rinsing with mouthwash B. Verify that the client has not eaten for the last 24 hours C. Have the client void immediately before going into surgery D. Report immediately any slight increase in BP or pulse The answer is C. 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. 19.) 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? A. Obtain a court order for the surgery. B. Have the charge nurse sign the informed consent immediately C. Send the client to surgery without the consent form being signed D. Obtain a telephone consent from a family member, following agency policy The answer is D. 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

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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 in this case it is not an emergency. 20.) 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? A. "If it's any help, everyone is nervous before surgery." B. "I will be happy to explain the entire surgical procedure with you." C. "Can you share with me what you've been told about your surgery?" D. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate". The answer is C. 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

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The answer is C. 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. 23.) 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? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm tender skin The answer is B. 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. 24.) 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 A. Contact the surgeon B. Instruct the client to remain quiet C. Prepare the client for wound closure D. Document the findings and actions taken E. Place a sterile saline dressing and ice packs over the wound

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F. Place the client in a prone position without a pillow under the head. The answers are A,B,C,D. 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. 25.) 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? A. Sodium, 141mEq/L B. Hemoglobin, 8.0 g/dL C. Platelets, 210,000/mm D. Serum creatine, 0.8 mg/dL The answer is B. 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.

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surgery, dosages may be increased temporarily. These last few medications may be withheld before surgery without undue effects on the client. 29.) A 67-year-old male patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? A.Increased respiratory rate B.Decreased oxygen saturation C.Increased carbon dioxide pressure D.Frequent premature ventricular contractions (PVCs) The answer is C. Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation. 30.) The nurse is caring for a 54-year-old unconscious female patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient? A. Left lateral position with head supported on a pillow B. Prone position with a pillow supporting the abdomen C. Supine position with head of bed elevated 30 degrees D.Semi-Fowler's position with the head turned to the right

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The answer is A. The unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

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a fever. 33.) The nurse cares for a 72-year-old Native American male patient 2 days after a thoracotomy for tumor resection. What would be the most appropriate action if the patient does not report any pain? A. Contact the health care provider. B. Identify possible reasons for denial of pain. C. Administer the prescribed pain medication. D. Assess the renal and liver function test results. The answer is B, identify all possible reasons for denial of pain after a surgical procedure has been done. 34.) The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? A. Assess the patient's pain. B. Assess the patient's vital signs. C. Check the rate of the IV infusion. D. Check the physician's postoperative orders. The answer is B. The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence. 35.) When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to

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this finding, what should the nurse do first? A. Recheck in 1 hour for increased drainage. B. Notify the surgeon of a potential hemorrhage. C. Assess the patient's blood pressure and heart rate. D. Remove the dressing and assess the surgical incision. The answer is C. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it. 36.) In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? A. Administering adequate analgesics to promote relief or control of pain B. Asking the patient to demonstrate the postoperative exercises every 1 hour C.Giving the patient positive feedback when the activities are performed correctly D. Warning the patient about possible complications if the activities are not performed 37.) Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? A. Atelectasis B. Bronchospasm