PERIOPERATIVE NCLEX QUESTIONS LATEST UPDATE 2024/2025 100% VERIFIED ANSWERS ACCURATE, Exams of Health sciences

Download PERIOPERATIVE NCLEX QUESTIONS LATEST UPDATE 2024/2025 100% VERIFIED ANSWERS ACCURATE and more Exams Health sciences in PDF only on Docsity! PERIOPERATIVE NCLEX QUESTIONS LATEST UPDATE 2024/2025 100% VERIFIED ANSWERS ACCURATE A 26-year old client comes into the clinic prior to a tonsillectomy. Which action is priority during this phase of surgery? a. Intraoperative consent signed b. Intraoperative medication c. Preoperative assessment d. Postoperative assessment c. Preoperative assessment The client is in the preoperative phase of surgery and must be assessed and prepared for surgery. The client may have labs drawn, medication administered, and consent forms signed. The intraoperative phase is the actual surgery; the client is anesthetized, prepped, draped, and surgery performed. The postoperative phase is the recovery phase of surgery where the client continues to recover until maximum health is achieved. A 76-year old client is to undergo a hernia repair. The nurse knows that in order to aid in the healing process, the perioperative nurse must assist the client with which concept during what surgical phase? a. Perfusion therapy during the intraoperative phase b. Wound healing during the postoperative phase c. Wound healing during the preoperative and intraoperative phase d. Infection during the postoperative phase c. Wound healing during the preoperative and intraoperative phase Inadequate control of stress and coping mechanisms can prolong the perioperative healing process and a client's prognosis. Perioperative care includes assessing client stress and coping mechanisms during the preoperative phase and reassessing following the procedure. Postoperative infections may occur as a result of improper wound care or hospital acquired infections may occur as a result of infection control protocols not being followed. Adequate perfusion enhances wound healing and perioperative recovery. Nurses providing intraoperative and postoperative care must follow infection protocols. A 65-year old client is having neck surgery. Which nursing diagnosis does the nurse include for this client? a. Risk for burns b. Risk for fluid volume: Deficient c. Ineffective pain control d. Risk for fluid volume: Excess b. Risk for fluid volume: Deficient Risk for Fluid Volume: Deficient is related to any blood loss during the client's surgery and NPO status. Risk for Burns is unrelated; there is no indication for Fluid Volume: Excess or Ineffective Pain Control. An 18-year old client is admitted to the emergency room for an emergency appendectomy. The nurse knows that which assessment is priority with each perioperative phase a. Medication assessment b. Pain assessment c. History and physical d. Systems assessment d. Systems assessment While the other assessments are important, a systems assessment is priority and can be completed with each perioperative phase, making sure the client remains at baseline throughout. A 43-year old client is undergoing a CABG. What priority understanding does the nurse have about perioperative documentation? a. If it was not written, it was not done b. It includes all steps of the nursing process c. It's a legal document subject to internal review The nurse measures the client's blood pressure, pulse, and capillary refill prior to sending the client to the operating room. Which concept related to perioperative care is the nurse implementing? a. Quality control b. Perfusion c. Safety d. Infection control b. Perfusion The concept of perfusion is related to perioperative care. Nurses must be aware of the client's hemodynamic status and understand the guidelines for perfusion. The client's hemodynamic status is measured through blood pressure, pulse, and capillary refill. Measuring blood pressure, pulse, and capillary refill does not directly support the concepts of safety, quality control, or infection control. A preoperative client asks if blood products will be used during the procedure. Which laboratory values should the nurse explain are used to determine the client's need for blood products? (SELECT ALL THAT APPLY) a. Hemoglobin b. Hematocrit c. Prothrombin time d. Red blood cell count e. Platelets a. Hemoglobin b. Hematocrit d. Red blood cell count e. Platelets The diagnostic tests of platelets, hematocrit, hemoglobin, and red blood cell count are used to determine if a blood transfusion is needed during the surgical procedure. Prothrombin time is used to determine the client's risk for bleeding. The nurse is preparing a client for a surgical procedure to remove a portion of the transverse colon. Which priority actions should the nurse include to reduce the client's risk of developing a postoperative complication? (SELECT ALL THAT APPLY) a. Observe for muscle twitching b. Monitor body temperature c. Monitor blood pressure and heart rate d. Ensure aseptic technique is used for the procedure e. Monitor urine concentration b. Monitor body temperature c. Monitor blood pressure and heart rate d. Ensure aseptic technique is used for the procedure Open procedures place the client at a higher risk for blood loss, hypothermia and surgical site infections (SSIs). The nurse should monitor body temperature, blood pressure, and heart rate and ensure aseptic technique is used for the procedure. Urine concentration is used to monitor for hypernatremia and hypovolemia. Muscle twitching is associated with hyponatremia. What postoperative assessment would indicate to the nurse a change in a client's cardiovascular status? (SELECT ALL THAT APPLY) a. Capillary refill time greater than 3 seconds b. Vomiting moderate amount of green emesis c. Absent gag reflex d. Pedal pulse non-palpable e. Dropping blood pressure a. Capillary refill time greater than 3 seconds d. Pedal pulse non-palpable e. Dropping blood pressure Changes in cardiovascular status affect blood pressure, pulses, and capillary refill. Dropping blood pressure, non-palpable pedal pulse, and capillary refill time greater than 3 seconds reflect a change in the cardiovascular status. An absent gag reflex indicates a change in a protective neurological reflex. Vomiting indicates a change in gastrointestinal status. The circulating nurse is ensuring that a client is adequately positioned for surgery and determines that the procedure is going to take longer than 30 minutes to complete. What did the nurse assess to make this determination? a. Client is in the lithotomy position b. Client has a device on a finger to measure oxygen saturation c. Client is wearing sequential compression devices d. Client has pillows placed under the knees c. Client is wearing sequential compression devices For procedures expected to last 30 minutes or longer, clients may be prescribed to wear sequential compression devices to reduce the risk of venous thromboembolism development from prolonged inactivity. The use of the lithotomy position does not determine the length of the surgical procedure. Placing pillows under the knees is a preventive action for the client in the supine position for a surgical procedure. Most clients receiving anesthesia will have oxygen saturation monitored during the surgical procedure. A 5-year old client scheduled for a tonsillectomy asks the nurse if the operation is going to hurt. What is the best response by the nurse? a. Yes, but it will hurt less than the sore throat you have now b. No, you will have no pain c. Yes, but we will give you medicine to stop the pain before it starts d. Yes, but don't worry. I can give you a shot to help with the pain c. Yes, but we will give you medicine to stop the pain before it starts Nurses preparing children for surgery should be honest regarding expectations about postoperative pain and how the care team is ready to respond and treat pain. The nurse should acknowledge that there will be pain but also explain that medicine can be used to stop the pain before it starts. Denying the presence of pain is not an honest response. Saying that the pain will be less than the client's current sore throat does not address how pain will be managed. Responding that pain medication will be provided with a shot could cause the child alarm. The nurse is conducting the preoperative assessment. The client reports having a cup of black coffee before arriving for the scheduled surgery. What should the nurse do with this information?