NCLEX RN: Perioperative Care Exam Test with Verified Answers 100%
Pass | 2025 Update
1. An 85-year-old 1. "We need to give you iodine to help in hemoglobin
client is hospital- synthesis."
ized for a frac- 2. "It is important for you to get out of bed so that calcium
tured right hip. will go back into the bone."
During the post- 3. "We need to increase your calcium intake because you
operative period, are spending too much time in bed."
the client's ap- 4. "You need to remember to turn yourself in bed every 2
petite is poor and hours to keep from getting so stiff."
the client refuses
to get out of bed. Rationale: Early ambulation in the postoperative period is
Which nursing important because if a client does not increase activity, the
statement would bones will suffer from loss of calcium. Iron, not iodine, is
be most appro- recommended for hemoglobin synthesis because oxygen
priate to make to is necessary for wound healing. Increasing calcium intake
the client? would cause elevated amounts of calcium in the blood,
which could lead to kidney stones. Clients who are not
turned in bed will develop pressure ulcers. An 85-year-old
who is immobile needs to be turned every 2 hours by
the nursing staff; clients should not be expected to turn
themselves.
2. A client has 1. Suction the client through the endotracheal tube.
had an inva- 2. Instruct the client in the use of an incentive spirometer.
sive abdominal 3. Turn the client from a 30-degree lateral position to a
surgery to relieve supine position.
an obstruction 4. Instruct the client to use a communication board to tell
of the common the nurse what is wrong.
bile duct. The
client's surgery Rationale: The client is choking on his secretions, which
is completed, should be removed by suctioning the endotracheal tube.
and the client has The client is unable to use an incentive spirometer while
been transferred an endotracheal tube is in place. The client's inability to
to the postanes- breathe impairs ability to learn how to use a communica-
thetic care tion board. Turning the client assists in clearing his airway,
unit (PACU). The but a supine position will worsen the airway problem. Suc-
PACU nurse ob- tioning the client is the best nursing intervention because
serves that the it will have the most immediate effect.
client suddenly
appears red in
, NCLEX RN: Perioperative Care Exam Test with Verified Answers 100%
Pass | 2025 Update
the face and
appears to be
coughing despite
the presence of
an endotracheal
tube and ventila-
tor support. What
action should the
PACU nurse take
first?
3. The nurse is 1. Call the surgeon immediately.
caring for a 2. Shake the client gently to arouse.
client who 3. Cover the client with a warm blanket.
recently 4. Recheck the vital signs in 15 minutes.
returned from
the operating Rationale: A drop in blood pressure slightly below a client's
room. On data preoperative baseline reading is common after surgery.
collection, the The nurse should recheck the vital signs. Warm blankets
nurse notes that are applied to maintain the client's body temperature. Lev-
the client's vital el of consciousness can be assessed by the evaluation of
signs are blood the client's response to light touch and verbal stimuli. It is
pressure (BP), not necessary to contact the surgeon immediately.
118/70 mm Hg;
pulse, 91
beats/minute;
and respirations,
16
breaths/minute.
Preoperative
vital signs were
BP, 132/88 mm
Hg; pulse, 74
beats/minute;
and respirations,
20
breaths/minute.
Which action
Pass | 2025 Update
1. An 85-year-old 1. "We need to give you iodine to help in hemoglobin
client is hospital- synthesis."
ized for a frac- 2. "It is important for you to get out of bed so that calcium
tured right hip. will go back into the bone."
During the post- 3. "We need to increase your calcium intake because you
operative period, are spending too much time in bed."
the client's ap- 4. "You need to remember to turn yourself in bed every 2
petite is poor and hours to keep from getting so stiff."
the client refuses
to get out of bed. Rationale: Early ambulation in the postoperative period is
Which nursing important because if a client does not increase activity, the
statement would bones will suffer from loss of calcium. Iron, not iodine, is
be most appro- recommended for hemoglobin synthesis because oxygen
priate to make to is necessary for wound healing. Increasing calcium intake
the client? would cause elevated amounts of calcium in the blood,
which could lead to kidney stones. Clients who are not
turned in bed will develop pressure ulcers. An 85-year-old
who is immobile needs to be turned every 2 hours by
the nursing staff; clients should not be expected to turn
themselves.
2. A client has 1. Suction the client through the endotracheal tube.
had an inva- 2. Instruct the client in the use of an incentive spirometer.
sive abdominal 3. Turn the client from a 30-degree lateral position to a
surgery to relieve supine position.
an obstruction 4. Instruct the client to use a communication board to tell
of the common the nurse what is wrong.
bile duct. The
client's surgery Rationale: The client is choking on his secretions, which
is completed, should be removed by suctioning the endotracheal tube.
and the client has The client is unable to use an incentive spirometer while
been transferred an endotracheal tube is in place. The client's inability to
to the postanes- breathe impairs ability to learn how to use a communica-
thetic care tion board. Turning the client assists in clearing his airway,
unit (PACU). The but a supine position will worsen the airway problem. Suc-
PACU nurse ob- tioning the client is the best nursing intervention because
serves that the it will have the most immediate effect.
client suddenly
appears red in
, NCLEX RN: Perioperative Care Exam Test with Verified Answers 100%
Pass | 2025 Update
the face and
appears to be
coughing despite
the presence of
an endotracheal
tube and ventila-
tor support. What
action should the
PACU nurse take
first?
3. The nurse is 1. Call the surgeon immediately.
caring for a 2. Shake the client gently to arouse.
client who 3. Cover the client with a warm blanket.
recently 4. Recheck the vital signs in 15 minutes.
returned from
the operating Rationale: A drop in blood pressure slightly below a client's
room. On data preoperative baseline reading is common after surgery.
collection, the The nurse should recheck the vital signs. Warm blankets
nurse notes that are applied to maintain the client's body temperature. Lev-
the client's vital el of consciousness can be assessed by the evaluation of
signs are blood the client's response to light touch and verbal stimuli. It is
pressure (BP), not necessary to contact the surgeon immediately.
118/70 mm Hg;
pulse, 91
beats/minute;
and respirations,
16
breaths/minute.
Preoperative
vital signs were
BP, 132/88 mm
Hg; pulse, 74
beats/minute;
and respirations,
20
breaths/minute.
Which action
