PERIOPERATIVE NURSING NCLEX QUESTIONS AND
ANSWERS LATEST VERSION VERIFIED RATIONALE
GRADED A+
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 interven�ons 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 ac�ons taken
5. Place a sterile saline dressing and icepacks over the wound
6. Place the client in a prone posi�on without a pillow under the head. - ans1, 2, 3 ,4
Wound dehiscence is the separa�on of the wound edges. Wound eviscera�on is protrusion of the
internal organs through an incision. If wound dehiscence or eviscera�on 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 posi�on 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 vasoconstric�ve effect. The treatment for eviscera�on is usually immediate wound closure
under local or general anesthesia. The nurse also documents the findings and ac�ons taken.
A client who has undergone preadmission tes�ng, has had blood drawn for serum lab studies, including
a complete blood count, coagula�on studies and electrolytes and crea�ne 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 crea�ne, 0.8 mg/dL - ansThe 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
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the opera�ve
consent form because of seda�on from opioid analgesics that have been administered. The nurse should
take which most appropriate ac�on in the care of this client?
1. Obtain a court order for the surgery.
, PERIOPERATIVE NURSING NCLEX QUESTIONS AND
ANSWERS LATEST VERSION VERIFIED RATIONALE
GRADED A+
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 - ans4.
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, no�ng 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 seda�ves.
In an emergency the client may not be able to sign and family members may not be available. In this
situa�on, a health care provider is permited legally to perform surgery without consent, but �n this case
it is not an emergency. Agency policies regarding informed consent should always be followed.
A postopera�ve client asks the nurse why it is so important to deep-breathe and cough a�er surgery.
When formula�ng a response, the nurse incorporates the understanding that retained pulmonary
secre�ons in a postopera�ve client can lead to which condi�on?
1. Pneumonia
2. Hypoxemia
3. Fluid imbalance
4. Pulmonary embolism - ans1.
Postopera�ve respiratory problems are atelectasis, pneumonia and pulmonary emboli. Pneumonia is the
inflamma�on of lung �ssue that causes produc�ve cough, dyspnea, and lung crackles and can be caused
by the reten�on of pulmonary secre�ons.
A preopera�ve client expresses anxiety to the nurse about upcoming surgery. Which response by the
nurse is most likely to s�mulate 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 en�re 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 a�er surgery and the amount of pain you can an�cipate".
- ans3.
ANSWERS LATEST VERSION VERIFIED RATIONALE
GRADED A+
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 interven�ons 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 ac�ons taken
5. Place a sterile saline dressing and icepacks over the wound
6. Place the client in a prone posi�on without a pillow under the head. - ans1, 2, 3 ,4
Wound dehiscence is the separa�on of the wound edges. Wound eviscera�on is protrusion of the
internal organs through an incision. If wound dehiscence or eviscera�on 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 posi�on 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 vasoconstric�ve effect. The treatment for eviscera�on is usually immediate wound closure
under local or general anesthesia. The nurse also documents the findings and ac�ons taken.
A client who has undergone preadmission tes�ng, has had blood drawn for serum lab studies, including
a complete blood count, coagula�on studies and electrolytes and crea�ne 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 crea�ne, 0.8 mg/dL - ansThe 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
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the opera�ve
consent form because of seda�on from opioid analgesics that have been administered. The nurse should
take which most appropriate ac�on in the care of this client?
1. Obtain a court order for the surgery.
, PERIOPERATIVE NURSING NCLEX QUESTIONS AND
ANSWERS LATEST VERSION VERIFIED RATIONALE
GRADED A+
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 - ans4.
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, no�ng 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 seda�ves.
In an emergency the client may not be able to sign and family members may not be available. In this
situa�on, a health care provider is permited legally to perform surgery without consent, but �n this case
it is not an emergency. Agency policies regarding informed consent should always be followed.
A postopera�ve client asks the nurse why it is so important to deep-breathe and cough a�er surgery.
When formula�ng a response, the nurse incorporates the understanding that retained pulmonary
secre�ons in a postopera�ve client can lead to which condi�on?
1. Pneumonia
2. Hypoxemia
3. Fluid imbalance
4. Pulmonary embolism - ans1.
Postopera�ve respiratory problems are atelectasis, pneumonia and pulmonary emboli. Pneumonia is the
inflamma�on of lung �ssue that causes produc�ve cough, dyspnea, and lung crackles and can be caused
by the reten�on of pulmonary secre�ons.
A preopera�ve client expresses anxiety to the nurse about upcoming surgery. Which response by the
nurse is most likely to s�mulate 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 en�re 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 a�er surgery and the amount of pain you can an�cipate".
- ans3.
