1. A client tells the nurse that he has no questions about his illness since he did a search on
the Internet. What should the nurse do?
Ask the client to share the information obtained from the internet search
2. A client's blood pressure on the post-anesthesia care unit (PACU) has dropped from an
admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is
92% on 3 L of oxygen. Which items are most important for the nurse to implement?
o Increase the IV infusion rate
o Increase the oxygen flow rate..
o Assess the patient's dressing.
o Check the patient's temperature
3. After receiving a change of shift report about these postoperative clients, which client
should the nurse assess first?
Obese patient who had abdominal surgery 3 days ago and whose wound edges
are separating
4. The nurse assesses a client on the second postoperative day after abdominal surgery to
repair a perforated duodenal ulcer. Which finding is most important for the nurse to
report to the surgeon?
200 mL sanguineous fluid in the wound drain
5. The nurse reviews the lab results for a client on the first postoperative day after an
abdominal surgery. Which finding would indicate to the nurse that the client is at
increased risk for poor wound healing?
Albumin level 2.2 g/L
6. The nurse is working in the post-anesthesia care unit (PACU) notes that a client who has
been transported from the operating room is shivering and has a temperature of 96.5.
Which action should the nurse take?
Cover the patient with a warm blanket and put on socks
7. A client who had knee surgery received Toradol 30 minutes ago and continues to
complain of pain at 7. Which action is best for the nurse to take at this time?
Administer the prescribed PRN IV morphine sulfate
8. The nurse is caring for a client the first post op following a laparotomy for a small bowel
obstruction. The nurse notices new bright red drainage about 5 cm in diameter on the
dressing which action should the nurse take first?
Take the patient's vital signs
9. A postop client has not voided for eight hours after returning to the clinical unit. Which
action should the nurse take first?
Perform a bladder scan
, 10. An older adult client who had knee replacement surgery 2 days ago can only tolerate
being out of bed with physical therapy once a day. Which collaborative problem should
the nurse identify as a priority?
Potential complication: Venous thromboembolism
11. A client is transferred from the PACU to the clinical unit. Which action by the nurse on
the clinical unit should be performed first?
Take the patient's vital signs
12. A nurse assists a client on the first preoperative day to ambulate, cough, deep breath
and turn. Which action by the nurse is most helpful?
Administer ordered analgesic medications before these activities
13. A client's T-tube is draining dark green fluid after gallbladder surgery. What action by
the nurse is most appropriate?
Document the color and amount of drainage
14. NG tube is removed on the second postoperative day, and the client is placed on a clear
liquid diet. Four hours later, the client complains of sharp, cramping gas pains. What
action by the nurse is most appropriate?
Assist the patient to ambulate
15. An experienced nurse is orienting new nurse to the PACU. Which action by the new
nurse is observed by the experienced nurse indicates that the orientation was successful?
The nurse turns an unconscious patients to the side upon arrival in the PACU
16. In the PACU a client's vital signs are blood pressure 116/72, pulse 74, respirations 12,
and spo2 91%. The client is sleepy, but awakens easily. Which action should the nurse
take first?
Encourage the patient to take deep breaths
17. On admission of a patient to the PACU, the blood pressure is 122/70. 30 minutes after
admission, the blood pressure falls to 114/62, with a pulse of 74 and warm, dry skin.
Which action by the nurse is most appropriate?
Continue to take vital signs every 15 minutes
18. The nurse is conducting a preoperative assessment. Which client does the nurse teach
about the possibility of developing DVT?
Client undergoing hip replacement surgery
19. A client is brought to the hospital unconscious and needs emergency surgery. The
client's only family member cannot come to the hospital before the surgery. Which is the
best option for obtaining informed consent for the client's emergency surgery?
Contact the family member by phone and obtain verbal consent with two witnesses
the Internet. What should the nurse do?
Ask the client to share the information obtained from the internet search
2. A client's blood pressure on the post-anesthesia care unit (PACU) has dropped from an
admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is
92% on 3 L of oxygen. Which items are most important for the nurse to implement?
o Increase the IV infusion rate
o Increase the oxygen flow rate..
o Assess the patient's dressing.
o Check the patient's temperature
3. After receiving a change of shift report about these postoperative clients, which client
should the nurse assess first?
Obese patient who had abdominal surgery 3 days ago and whose wound edges
are separating
4. The nurse assesses a client on the second postoperative day after abdominal surgery to
repair a perforated duodenal ulcer. Which finding is most important for the nurse to
report to the surgeon?
200 mL sanguineous fluid in the wound drain
5. The nurse reviews the lab results for a client on the first postoperative day after an
abdominal surgery. Which finding would indicate to the nurse that the client is at
increased risk for poor wound healing?
Albumin level 2.2 g/L
6. The nurse is working in the post-anesthesia care unit (PACU) notes that a client who has
been transported from the operating room is shivering and has a temperature of 96.5.
Which action should the nurse take?
Cover the patient with a warm blanket and put on socks
7. A client who had knee surgery received Toradol 30 minutes ago and continues to
complain of pain at 7. Which action is best for the nurse to take at this time?
Administer the prescribed PRN IV morphine sulfate
8. The nurse is caring for a client the first post op following a laparotomy for a small bowel
obstruction. The nurse notices new bright red drainage about 5 cm in diameter on the
dressing which action should the nurse take first?
Take the patient's vital signs
9. A postop client has not voided for eight hours after returning to the clinical unit. Which
action should the nurse take first?
Perform a bladder scan
, 10. An older adult client who had knee replacement surgery 2 days ago can only tolerate
being out of bed with physical therapy once a day. Which collaborative problem should
the nurse identify as a priority?
Potential complication: Venous thromboembolism
11. A client is transferred from the PACU to the clinical unit. Which action by the nurse on
the clinical unit should be performed first?
Take the patient's vital signs
12. A nurse assists a client on the first preoperative day to ambulate, cough, deep breath
and turn. Which action by the nurse is most helpful?
Administer ordered analgesic medications before these activities
13. A client's T-tube is draining dark green fluid after gallbladder surgery. What action by
the nurse is most appropriate?
Document the color and amount of drainage
14. NG tube is removed on the second postoperative day, and the client is placed on a clear
liquid diet. Four hours later, the client complains of sharp, cramping gas pains. What
action by the nurse is most appropriate?
Assist the patient to ambulate
15. An experienced nurse is orienting new nurse to the PACU. Which action by the new
nurse is observed by the experienced nurse indicates that the orientation was successful?
The nurse turns an unconscious patients to the side upon arrival in the PACU
16. In the PACU a client's vital signs are blood pressure 116/72, pulse 74, respirations 12,
and spo2 91%. The client is sleepy, but awakens easily. Which action should the nurse
take first?
Encourage the patient to take deep breaths
17. On admission of a patient to the PACU, the blood pressure is 122/70. 30 minutes after
admission, the blood pressure falls to 114/62, with a pulse of 74 and warm, dry skin.
Which action by the nurse is most appropriate?
Continue to take vital signs every 15 minutes
18. The nurse is conducting a preoperative assessment. Which client does the nurse teach
about the possibility of developing DVT?
Client undergoing hip replacement surgery
19. A client is brought to the hospital unconscious and needs emergency surgery. The
client's only family member cannot come to the hospital before the surgery. Which is the
best option for obtaining informed consent for the client's emergency surgery?
Contact the family member by phone and obtain verbal consent with two witnesses
