HESI Attempt 2 Nursing Care
Interventions Postoperative
Management Exam — Complete Practice
Questions & Detailed Rationales (Verified
Update!!!!! 2026–2027 Edition)
1. A postoperative client has a respiratory rate of 8/min and is difficult to arouse
after receiving IV opioid medication. What is the nurse's priority action?
A. Encourage the client to cough
B. Administer the prescribed opioid
C. Assess airway and respiratory status
D. Place the client in a supine position
Answer: C. Assess airway and respiratory status
Rationale: Opioids can cause respiratory depression. Airway and breathing are
immediate priorities. The nurse should assess the client and provide appropriate
emergency interventions according to the clinical situation.
2. Which postoperative finding requires the most immediate intervention?
A. Pain rated 6/10
B. Oxygen saturation of 86%
C. Temperature of 37.7°C (99.9°F)
D. Urine output of 40 mL/hr
Answer: B. Oxygen saturation of 86%
Rationale: Significant hypoxemia threatens life and requires prompt assessment
and intervention.
,3. A postoperative client is at increased risk for atelectasis primarily because of:
A. Increased appetite
B. Shallow breathing and decreased mobility
C. Increased urinary output
D. Increased bowel activity
Answer: B. Shallow breathing and decreased mobility
Rationale: Pain, anesthesia, and immobility can reduce deep ventilation and
promote alveolar collapse.
4. Which intervention is most effective for preventing postoperative atelectasis?
A. Restricting fluids
B. Encouraging incentive spirometry
C. Keeping the client on bed rest
D. Avoiding coughing
Answer: B. Encouraging incentive spirometry
Rationale: Incentive spirometry promotes deep inspiration and helps expand
alveoli.
5. The nurse teaches a postoperative client how to splint the incision. What is
the purpose?
A. Prevent infection
B. Reduce pain during coughing
C. Increase blood pressure
D. Prevent urinary retention
Answer: B. Reduce pain during coughing
Rationale: Supporting the incision with a pillow or the hands can decrease
discomfort while coughing and promote effective secretion clearance.
,6. Which postoperative client should the nurse assess first?
A. Client reporting incisional pain of 5/10
B. Client with oxygen saturation of 89% and increasing dyspnea
C. Client requesting assistance with toileting
D. Client with mild nausea
Answer: B. Client with oxygen saturation of 89% and increasing dyspnea
Rationale: Airway and breathing problems take priority over pain, toileting, and
mild nausea.
7. Which position is generally appropriate for a postoperative client who is
experiencing respiratory difficulty?
A. Flat supine
B. High-Fowler's
C. Prone with the head turned
D. Trendelenburg
Answer: B. High-Fowler's
Rationale: Elevating the head of the bed can improve lung expansion and
decrease the work of breathing.
8. Which finding is most concerning for postoperative hemorrhage?
A. Blood pressure 88/54 mmHg with tachycardia
B. Mild incisional discomfort
C. Temperature 37.2°C
D. Urine output of 50 mL/hr
Answer: A. Blood pressure 88/54 mmHg with tachycardia
Rationale: Hypotension and tachycardia can indicate significant blood loss and
hypovolemia.
, 9. A postoperative client's dressing becomes rapidly saturated with bright-red
blood. What should the nurse do first?
A. Remove the dressing and discard it
B. Assess the client and vital signs
C. Wait until the next scheduled dressing change
D. Encourage ambulation
Answer: B. Assess the client and vital signs
Rationale: Rapid bleeding may represent hemorrhage. The nurse should
immediately assess the client's hemodynamic status and notify the appropriate
provider/emergency team.
10. Which finding may indicate hypovolemic shock?
A. Bradycardia and hypertension
B. Tachycardia, hypotension, and cool skin
C. Warm skin and slow pulse
D. Increased urine output
Answer: B. Tachycardia, hypotension, and cool skin
Rationale: Reduced circulating volume activates compensatory mechanisms,
commonly producing tachycardia, vasoconstriction, cool skin, and eventually
hypotension.
11. Which postoperative intervention helps prevent venous thromboembolism?
A. Prolonged bed rest
B. Early ambulation
C. Limiting leg movement
D. Placing pillows directly behind the knees continuously
Interventions Postoperative
Management Exam — Complete Practice
Questions & Detailed Rationales (Verified
Update!!!!! 2026–2027 Edition)
1. A postoperative client has a respiratory rate of 8/min and is difficult to arouse
after receiving IV opioid medication. What is the nurse's priority action?
A. Encourage the client to cough
B. Administer the prescribed opioid
C. Assess airway and respiratory status
D. Place the client in a supine position
Answer: C. Assess airway and respiratory status
Rationale: Opioids can cause respiratory depression. Airway and breathing are
immediate priorities. The nurse should assess the client and provide appropriate
emergency interventions according to the clinical situation.
2. Which postoperative finding requires the most immediate intervention?
A. Pain rated 6/10
B. Oxygen saturation of 86%
C. Temperature of 37.7°C (99.9°F)
D. Urine output of 40 mL/hr
Answer: B. Oxygen saturation of 86%
Rationale: Significant hypoxemia threatens life and requires prompt assessment
and intervention.
,3. A postoperative client is at increased risk for atelectasis primarily because of:
A. Increased appetite
B. Shallow breathing and decreased mobility
C. Increased urinary output
D. Increased bowel activity
Answer: B. Shallow breathing and decreased mobility
Rationale: Pain, anesthesia, and immobility can reduce deep ventilation and
promote alveolar collapse.
4. Which intervention is most effective for preventing postoperative atelectasis?
A. Restricting fluids
B. Encouraging incentive spirometry
C. Keeping the client on bed rest
D. Avoiding coughing
Answer: B. Encouraging incentive spirometry
Rationale: Incentive spirometry promotes deep inspiration and helps expand
alveoli.
5. The nurse teaches a postoperative client how to splint the incision. What is
the purpose?
A. Prevent infection
B. Reduce pain during coughing
C. Increase blood pressure
D. Prevent urinary retention
Answer: B. Reduce pain during coughing
Rationale: Supporting the incision with a pillow or the hands can decrease
discomfort while coughing and promote effective secretion clearance.
,6. Which postoperative client should the nurse assess first?
A. Client reporting incisional pain of 5/10
B. Client with oxygen saturation of 89% and increasing dyspnea
C. Client requesting assistance with toileting
D. Client with mild nausea
Answer: B. Client with oxygen saturation of 89% and increasing dyspnea
Rationale: Airway and breathing problems take priority over pain, toileting, and
mild nausea.
7. Which position is generally appropriate for a postoperative client who is
experiencing respiratory difficulty?
A. Flat supine
B. High-Fowler's
C. Prone with the head turned
D. Trendelenburg
Answer: B. High-Fowler's
Rationale: Elevating the head of the bed can improve lung expansion and
decrease the work of breathing.
8. Which finding is most concerning for postoperative hemorrhage?
A. Blood pressure 88/54 mmHg with tachycardia
B. Mild incisional discomfort
C. Temperature 37.2°C
D. Urine output of 50 mL/hr
Answer: A. Blood pressure 88/54 mmHg with tachycardia
Rationale: Hypotension and tachycardia can indicate significant blood loss and
hypovolemia.
, 9. A postoperative client's dressing becomes rapidly saturated with bright-red
blood. What should the nurse do first?
A. Remove the dressing and discard it
B. Assess the client and vital signs
C. Wait until the next scheduled dressing change
D. Encourage ambulation
Answer: B. Assess the client and vital signs
Rationale: Rapid bleeding may represent hemorrhage. The nurse should
immediately assess the client's hemodynamic status and notify the appropriate
provider/emergency team.
10. Which finding may indicate hypovolemic shock?
A. Bradycardia and hypertension
B. Tachycardia, hypotension, and cool skin
C. Warm skin and slow pulse
D. Increased urine output
Answer: B. Tachycardia, hypotension, and cool skin
Rationale: Reduced circulating volume activates compensatory mechanisms,
commonly producing tachycardia, vasoconstriction, cool skin, and eventually
hypotension.
11. Which postoperative intervention helps prevent venous thromboembolism?
A. Prolonged bed rest
B. Early ambulation
C. Limiting leg movement
D. Placing pillows directly behind the knees continuously
