NCLEX PERIOPERATIVE TEST BANK NEWEST
EXIT EXAM 2024 49 QUESTIONS AD
ANSWERS WITH VERIFIED RATIONALES
ALREADY GRADED A+| REAL EXAM| STUDY
TO PASS!!!
The nurse checks the postoperative client for signs of infection. Which observations are indicative of a
potential infection? Select all that apply.
1.Slight redness along the incision
2.The presence of purulent drainage
3.A temperature of 98.8° F (37.1° C)
4.The client states that he feels cold.
5.The client states that the incision itches.
6.Tender firmness palpable around the incision - ANSWERS -2.The presence of purulent drainage
6.Tender firmness palpable around the incision
Rationale:A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the
wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of
skin around the incision. The client may have fever and chills. Purulent material may exit from drains or
from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was
contaminated before surgical exploration; it appears 3 to 6 days after surgery. Slight redness along an
incision is a sign of inflammation and should be monitored to determine whether it progresses. A
temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Itching around a
wound may be from irritation or dryness and is not associated with infection. The fact that a client feels
cold is not indicative of an infection, although chills and fever are signs of infection. The room
temperature may be too cold for client comfort.
,Test-Taking Strategy(ies):Focus on the subject, wound infection. Noting the words purulent, tender, and
hardness will direct you to the correct options.Review:The signs of a wound infection.Color Key:Cyan =
StrategyMagenta = Content Review
The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal
surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all
that apply.
1.Wound care
2.Personal hygiene
3.Activity restrictions
4.Frequent assessment of vital signs
5.Coughing and deep breathing exercises
6.Pain monitoring and medications to relieve pain - ANSWERS -4.Frequent assessment of vital signs
5.Coughing and deep breathing exercises
6.Pain monitoring and medications to relieve pain
Rationale:The type of planning and instruction required varies with each individual and type of surgery.
Preoperative education, including rationales related to a client's expected postoperative behavior, has a
positive outcome on recovery and prevention of postoperative complications. Postoperatively, the client
will be monitored closely with vital signs and the client should understand this is routine. General
anesthesia predisposes clients to respiratory problems that can lead to atelectasis and pneumonia in the
postoperative period. Therefore, coughing and deep breathing are important exercises to be taught in
the preoperative period. Addressing that pain will be monitored and controlled with prescribed
analgesia should allay client fears regarding pain. Specific instructions that the client needs to receive
before discharge should include wound care, activity restrictions, dietary instructions, postoperative
medication instructions, personal hygiene, and follow-up appointments.
Test-Taking Strategy(ies):Focus on the subject, preoperative instructions. Options 1, 2, and 3 refer to
information that needs to be taught postoperatively. Options 4, 5, and 6 refer to information that
should be taught preoperatively.
Review:Preoperative and postoperative care.Color Key:Cyan = StrategyMagenta = Content Review
,The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the
surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital
signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute,
and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data,
which actions should the nurse take before notifying the registered nurse? Select all that apply.
1.Auscultate breath sounds.
2.Review vital signs from previous hour.
3.Observe the urinary catheter for patency and flow.
4.Observe the IV site for patency and correct flow rate.
5.Review when the client last received pain medication - ANSWERS -2.Review vital signs from previous
hour.
3.Observe the urinary catheter for patency and flow.
4.Observe the IV site for patency and correct flow rate.
5.Review when the client last received pain medication
Postoperative vital signs and urinary output are important parameters to determine how the client is
recovering from the surgical procedure. The nurse needs to consider if this data is an early sign of a
complication. The nurse should review the previous vital signs to determine whether this is a change
from how the vital signs have been trending since the BP is slightly low and the pulse rate is slightly fast.
Noting when the last pain medication was administered will help the nurse determine whether the vital
signs may be affected from the medication since opioids lower blood pressure. The nurse should
determine whether the IV fluid is infusing correctly and whether the catheter is patent. Urine output
should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for each of 2
consecutive hours should be reported. The client's preoperative or baseline blood pressure is used to
make informed postoperative comparisons. Auscultation of breath sounds is not part of determining the
significance of the vital signs and urinary output.
Focus on the subject, assessment of a postoperative client. To answer this question correctly, you must
know the normal ranges for temperature, blood pressure, and urinary output. The BP must be
compared to trends for this particular client. You also need to consider whether fluid is being
administered correctly and output is being measured correctly. By checking the situation thoroughly, the
nurse can determine whether to report the findings to the registered nurse.
The nurse is preparing a client for surgery. Which should be components of the plan of care? Select all
that apply.
, 1.Verify the preoperative laboratory studies were drawn.
2.Report any increases in blood pressure (BP) on the day of surgery. 3.Verify that the client has received
nothing by mouth (NPO) for 24 hours before surgery.
4.Instruct the client not to swallow water with oral hygiene on the morning of surgery.
5.Document that any medications the client was instructed to take before surgery are given. - ANSWERS
-4.Instruct the client not to swallow water with oral hygiene on the morning of surgery.
5.Document that any medications the client was instructed to take before surgery are given.
The preoperative preparation is important to ensure that the surgery gets done with everything ready to
ensure a successful outcome. The client may brush teeth and rinse with mouthwash but must not
swallow any water. Any specific medications that the client was instructed to take on the day of surgery
need to be administered and documented. This may include insulin or a blood pressure medication. The
nurse cannot just verify the preoperative testing was done. The nurse needs to review the results of the
preoperative laboratory studies and notify the primary health care provider of any abnormal results.
Some increase in both blood pressure and pulse is common because of client anxiety regarding surgery.
The client usually has a restriction of food and fluids for 8 hours before surgery instead of 24 hours.
Note the subject, preparing a client for surgery. Read each option carefully and decide whether it
promotes client safety when answering the question. Preoperative testing results, NPO status, and
medications ordered need to be documented as done. Any concerns regarding laboratory results or the
medications should be discussed with the primary health care provider. Recall that surgery can produce
anxiety and elevate BP slightly.
Following a surgical procedure, the nurse applies sequential compression devices to both lower
extremities and turns the machine on. The nurse implements this intervention for which purpose?
1.To promote arterial circulation
2.To prevent muscle cramps in the legs
3.To prevent thrombosis formation in the veins
4.To maintain muscle strength despite inactivity - ANSWERS -3.To prevent thrombosis formation in the
veins
EXIT EXAM 2024 49 QUESTIONS AD
ANSWERS WITH VERIFIED RATIONALES
ALREADY GRADED A+| REAL EXAM| STUDY
TO PASS!!!
The nurse checks the postoperative client for signs of infection. Which observations are indicative of a
potential infection? Select all that apply.
1.Slight redness along the incision
2.The presence of purulent drainage
3.A temperature of 98.8° F (37.1° C)
4.The client states that he feels cold.
5.The client states that the incision itches.
6.Tender firmness palpable around the incision - ANSWERS -2.The presence of purulent drainage
6.Tender firmness palpable around the incision
Rationale:A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the
wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of
skin around the incision. The client may have fever and chills. Purulent material may exit from drains or
from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was
contaminated before surgical exploration; it appears 3 to 6 days after surgery. Slight redness along an
incision is a sign of inflammation and should be monitored to determine whether it progresses. A
temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Itching around a
wound may be from irritation or dryness and is not associated with infection. The fact that a client feels
cold is not indicative of an infection, although chills and fever are signs of infection. The room
temperature may be too cold for client comfort.
,Test-Taking Strategy(ies):Focus on the subject, wound infection. Noting the words purulent, tender, and
hardness will direct you to the correct options.Review:The signs of a wound infection.Color Key:Cyan =
StrategyMagenta = Content Review
The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal
surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all
that apply.
1.Wound care
2.Personal hygiene
3.Activity restrictions
4.Frequent assessment of vital signs
5.Coughing and deep breathing exercises
6.Pain monitoring and medications to relieve pain - ANSWERS -4.Frequent assessment of vital signs
5.Coughing and deep breathing exercises
6.Pain monitoring and medications to relieve pain
Rationale:The type of planning and instruction required varies with each individual and type of surgery.
Preoperative education, including rationales related to a client's expected postoperative behavior, has a
positive outcome on recovery and prevention of postoperative complications. Postoperatively, the client
will be monitored closely with vital signs and the client should understand this is routine. General
anesthesia predisposes clients to respiratory problems that can lead to atelectasis and pneumonia in the
postoperative period. Therefore, coughing and deep breathing are important exercises to be taught in
the preoperative period. Addressing that pain will be monitored and controlled with prescribed
analgesia should allay client fears regarding pain. Specific instructions that the client needs to receive
before discharge should include wound care, activity restrictions, dietary instructions, postoperative
medication instructions, personal hygiene, and follow-up appointments.
Test-Taking Strategy(ies):Focus on the subject, preoperative instructions. Options 1, 2, and 3 refer to
information that needs to be taught postoperatively. Options 4, 5, and 6 refer to information that
should be taught preoperatively.
Review:Preoperative and postoperative care.Color Key:Cyan = StrategyMagenta = Content Review
,The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the
surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital
signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute,
and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data,
which actions should the nurse take before notifying the registered nurse? Select all that apply.
1.Auscultate breath sounds.
2.Review vital signs from previous hour.
3.Observe the urinary catheter for patency and flow.
4.Observe the IV site for patency and correct flow rate.
5.Review when the client last received pain medication - ANSWERS -2.Review vital signs from previous
hour.
3.Observe the urinary catheter for patency and flow.
4.Observe the IV site for patency and correct flow rate.
5.Review when the client last received pain medication
Postoperative vital signs and urinary output are important parameters to determine how the client is
recovering from the surgical procedure. The nurse needs to consider if this data is an early sign of a
complication. The nurse should review the previous vital signs to determine whether this is a change
from how the vital signs have been trending since the BP is slightly low and the pulse rate is slightly fast.
Noting when the last pain medication was administered will help the nurse determine whether the vital
signs may be affected from the medication since opioids lower blood pressure. The nurse should
determine whether the IV fluid is infusing correctly and whether the catheter is patent. Urine output
should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for each of 2
consecutive hours should be reported. The client's preoperative or baseline blood pressure is used to
make informed postoperative comparisons. Auscultation of breath sounds is not part of determining the
significance of the vital signs and urinary output.
Focus on the subject, assessment of a postoperative client. To answer this question correctly, you must
know the normal ranges for temperature, blood pressure, and urinary output. The BP must be
compared to trends for this particular client. You also need to consider whether fluid is being
administered correctly and output is being measured correctly. By checking the situation thoroughly, the
nurse can determine whether to report the findings to the registered nurse.
The nurse is preparing a client for surgery. Which should be components of the plan of care? Select all
that apply.
, 1.Verify the preoperative laboratory studies were drawn.
2.Report any increases in blood pressure (BP) on the day of surgery. 3.Verify that the client has received
nothing by mouth (NPO) for 24 hours before surgery.
4.Instruct the client not to swallow water with oral hygiene on the morning of surgery.
5.Document that any medications the client was instructed to take before surgery are given. - ANSWERS
-4.Instruct the client not to swallow water with oral hygiene on the morning of surgery.
5.Document that any medications the client was instructed to take before surgery are given.
The preoperative preparation is important to ensure that the surgery gets done with everything ready to
ensure a successful outcome. The client may brush teeth and rinse with mouthwash but must not
swallow any water. Any specific medications that the client was instructed to take on the day of surgery
need to be administered and documented. This may include insulin or a blood pressure medication. The
nurse cannot just verify the preoperative testing was done. The nurse needs to review the results of the
preoperative laboratory studies and notify the primary health care provider of any abnormal results.
Some increase in both blood pressure and pulse is common because of client anxiety regarding surgery.
The client usually has a restriction of food and fluids for 8 hours before surgery instead of 24 hours.
Note the subject, preparing a client for surgery. Read each option carefully and decide whether it
promotes client safety when answering the question. Preoperative testing results, NPO status, and
medications ordered need to be documented as done. Any concerns regarding laboratory results or the
medications should be discussed with the primary health care provider. Recall that surgery can produce
anxiety and elevate BP slightly.
Following a surgical procedure, the nurse applies sequential compression devices to both lower
extremities and turns the machine on. The nurse implements this intervention for which purpose?
1.To promote arterial circulation
2.To prevent muscle cramps in the legs
3.To prevent thrombosis formation in the veins
4.To maintain muscle strength despite inactivity - ANSWERS -3.To prevent thrombosis formation in the
veins
