Nursing 1 Final Exam 93 Questions with Verified Answers
A client has arrived in the postoperative unit. What action by the circulating nurse
takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report - CORRECT ANSWER ANS: D
Hand-offs are a critical time in client care, and poor communication during this
time can lead to serious errors. The postoperative nurse and circulating nurse
participate in hand-off report as the priority. Assessing fluid losses and dressings
can be done together as part of the report. Ensuring the client is warm is a lower
priority.
The postanesthesia care unit (PACU) charge nurse notes vital signs on four
postoperative clients. Which client should the nurse assess first?
a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respiratory rate of 6 breaths/min
d. Client with a temperature of 96° F (35.6° C) - CORRECT ANSWER ANS: C
The respiratory rate is the most critical vital sign for any client who has undergone
general anesthesia or moderate sedation, or has received opioid analgesia. This
respiratory rate is too low and indicates respiratory depression. The nurse should
assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may
be within that client's baseline. A pulse of 118 beats/min is slightly fast, which
could be due to several causes, including pain and anxiety. A temperature of 96° F
is slightly low and the client needs to be warmed. But none of these other vital
signs take priority over the respiratory rate.
A postoperative nurse is caring for a client whose oxygen saturation dropped
from 98% to 95%. What action by the nurse is most appropriate?
a. Assess other indicators of oxygenation.
b. Call the Rapid Response Team.
c. Notify the anesthesia provider.
d. Prepare to intubate the client. - CORRECT ANSWER ANS: A
,If a postoperative client's oxygen saturation (SaO2) drops below 95% (or the
client's baseline), the nurse should notify the anesthesia provider. If the SaO2
drops by 10% or more, the nurse should call the Rapid Response Team. Since this
is approximately a 3% drop, the nurse should further assess the client. Intubation
(if the client is not intubated already) is not warranted.
Ten hours after surgery, a postoperative client reports that the antiembolism
stockings and sequential compression devices itch and are too hot. The client asks
the nurse to remove them. What response by the nurse is best?
a. "Let me call the surgeon to see if you really need them."
b. "No, you have to use those for 24 hours after surgery."
c. "OK, we can remove them since you are stable now."
d. "To prevent blood clots you need them a few more hours." - CORRECT ANSWER
ANS: D
According to the Surgical Care Improvement Project (SCIP), any prophylactic
measures to prevent thromboembolic events during surgery are continued for 24
hours afterward. The nurse should explain this to the client. Calling the surgeon is
not warranted. Simply telling the client he or she has to wear the hose and
compression devices does not educate the client. The nurse should not remove
the devices.
A client had a surgical procedure with spinal anesthesia. The nurse raises the head
of the client's bed. The client's blood pressure changes from 122/78 mm Hg to
102/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Lower the head of the bed.
d. Nothing; this is expected. - CORRECT ANSWER ANS: C
A client who had epidural or spinal anesthesia may become hypotensive when the
head of the bed is raised. If this occurs, the nurse should lower the head of the
bed to its original position. The Rapid Response Team is not needed, nor is an
increase in IV rate.
A postoperative client vomited. After cleaning and comforting the client, which
action by the nurse is most important?
a. Allow the client to rest.
b. Auscultate lung sounds.
,c. Document the episode.
d. Encourage the client to eat dry toast. - CORRECT ANSWER ANS: B
Vomiting after surgery has several complications, including aspiration. The nurse
should listen to the client's lung sounds. The client should be allowed to rest after
an assessment. Documenting is important, but the nurse needs to be able to
document fully, including an assessment. The client should not eat until nausea
has subsided.
A postoperative client has just been admitted to the postanesthesia care unit
(PACU). What assessment by the PACU nurse takes priority?
a. Airway
b. Bleeding
c. Breathing
d. Cardiac rhythm - CORRECT ANSWER ANS: A
Assessing the airway always takes priority, followed by breathing and circulation.
Bleeding is part of the circulation assessment, as is cardiac rhythm.
A postoperative client has respiratory depression after receiving midazolam
(Versed) for sedation. Which IV-push medication and dose does the nurse prepare
to administer?
a. Flumazenil (Romazicon) 0.2 to 1 mg
b. Flumazenil (Romazicon) 2 to 10 mg
c. Naloxone (Narcan) 0.4 to 2 mg
d. Naloxone (Narcan) 4 to 20 mg - CORRECT ANSWER ANS: A
Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in
this situation. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.
A nurse is caring for a postoperative client who reports discomfort, but denies
serious pain and does not want medication. What action by the nurse is best to
promote comfort?
a. Assess the client's pain on a 0-to-10 scale.
b. Assist the client into a position of comfort.
c. Have the client sit up in a recliner.
d. Tell the client when pain medication is due. - CORRECT ANSWER ANS: B
Several nonpharmacologic comfort measures can help postoperative clients with
their pain, including distraction, music, massage, guided imagery, and positioning.
The nurse should help this client into a position of comfort considering the
, surgical procedure and position of any tubes or drains. Assessing the client's pain
is important but does not improve comfort. The client may be more
uncomfortable in a recliner. Letting the client know when pain medication can be
given next is important but does not improve comfort.
A nurse is preparing a client for discharge after surgery. The client needs to
change a large dressing and manage a drain at home. What instruction by the
nurse is most important?
a. "Be sure you keep all your postoperative appointments."
b. "Call your surgeon if you have any questions at home."
c. "Eat a diet high in protein, iron, zinc, and vitamin C."
d. "Wash your hands before touching the drain or dressing." - CORRECT ANSWER
ANS: D
All options are appropriate for the client being discharged after surgery. However,
for this client who is changing a dressing and managing a drain, infection control
is the priority. The nurse should instruct the client to wash hands often, including
before and after touching the dressing or drain.
An older adult has been transferred to the postoperative inpatient unit after
surgery. The family is concerned that the client is not waking up quickly and states
"She needs to get back to her old self!" What response by the nurse is best?
a. "Everyone comes out of surgery differently."
b. "Let's just give her some more time, okay?"
c. "She may have had a stroke during surgery."
d. "Sometimes older people take longer to wake up." - CORRECT ANSWER ANS: D
Due to age-related changes, it may take longer for an older adult to metabolize
anesthetic agents and pain medications, making it appear that they are taking too
long to wake up and return to their normal baseline cognitive status. The nurse
should educate the family on this possibility. While everyone does react
differently, this does not give the family any objective information. Saying "Let's
just give her more time, okay?" sounds patronizing and again does not provide
information. While an intraoperative stroke is a possibility, the nurse should
concentrate on the more common occurrence of older clients taking longer to
fully arouse and awake.
A client has arrived in the postoperative unit. What action by the circulating nurse
takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report - CORRECT ANSWER ANS: D
Hand-offs are a critical time in client care, and poor communication during this
time can lead to serious errors. The postoperative nurse and circulating nurse
participate in hand-off report as the priority. Assessing fluid losses and dressings
can be done together as part of the report. Ensuring the client is warm is a lower
priority.
The postanesthesia care unit (PACU) charge nurse notes vital signs on four
postoperative clients. Which client should the nurse assess first?
a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respiratory rate of 6 breaths/min
d. Client with a temperature of 96° F (35.6° C) - CORRECT ANSWER ANS: C
The respiratory rate is the most critical vital sign for any client who has undergone
general anesthesia or moderate sedation, or has received opioid analgesia. This
respiratory rate is too low and indicates respiratory depression. The nurse should
assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may
be within that client's baseline. A pulse of 118 beats/min is slightly fast, which
could be due to several causes, including pain and anxiety. A temperature of 96° F
is slightly low and the client needs to be warmed. But none of these other vital
signs take priority over the respiratory rate.
A postoperative nurse is caring for a client whose oxygen saturation dropped
from 98% to 95%. What action by the nurse is most appropriate?
a. Assess other indicators of oxygenation.
b. Call the Rapid Response Team.
c. Notify the anesthesia provider.
d. Prepare to intubate the client. - CORRECT ANSWER ANS: A
,If a postoperative client's oxygen saturation (SaO2) drops below 95% (or the
client's baseline), the nurse should notify the anesthesia provider. If the SaO2
drops by 10% or more, the nurse should call the Rapid Response Team. Since this
is approximately a 3% drop, the nurse should further assess the client. Intubation
(if the client is not intubated already) is not warranted.
Ten hours after surgery, a postoperative client reports that the antiembolism
stockings and sequential compression devices itch and are too hot. The client asks
the nurse to remove them. What response by the nurse is best?
a. "Let me call the surgeon to see if you really need them."
b. "No, you have to use those for 24 hours after surgery."
c. "OK, we can remove them since you are stable now."
d. "To prevent blood clots you need them a few more hours." - CORRECT ANSWER
ANS: D
According to the Surgical Care Improvement Project (SCIP), any prophylactic
measures to prevent thromboembolic events during surgery are continued for 24
hours afterward. The nurse should explain this to the client. Calling the surgeon is
not warranted. Simply telling the client he or she has to wear the hose and
compression devices does not educate the client. The nurse should not remove
the devices.
A client had a surgical procedure with spinal anesthesia. The nurse raises the head
of the client's bed. The client's blood pressure changes from 122/78 mm Hg to
102/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Lower the head of the bed.
d. Nothing; this is expected. - CORRECT ANSWER ANS: C
A client who had epidural or spinal anesthesia may become hypotensive when the
head of the bed is raised. If this occurs, the nurse should lower the head of the
bed to its original position. The Rapid Response Team is not needed, nor is an
increase in IV rate.
A postoperative client vomited. After cleaning and comforting the client, which
action by the nurse is most important?
a. Allow the client to rest.
b. Auscultate lung sounds.
,c. Document the episode.
d. Encourage the client to eat dry toast. - CORRECT ANSWER ANS: B
Vomiting after surgery has several complications, including aspiration. The nurse
should listen to the client's lung sounds. The client should be allowed to rest after
an assessment. Documenting is important, but the nurse needs to be able to
document fully, including an assessment. The client should not eat until nausea
has subsided.
A postoperative client has just been admitted to the postanesthesia care unit
(PACU). What assessment by the PACU nurse takes priority?
a. Airway
b. Bleeding
c. Breathing
d. Cardiac rhythm - CORRECT ANSWER ANS: A
Assessing the airway always takes priority, followed by breathing and circulation.
Bleeding is part of the circulation assessment, as is cardiac rhythm.
A postoperative client has respiratory depression after receiving midazolam
(Versed) for sedation. Which IV-push medication and dose does the nurse prepare
to administer?
a. Flumazenil (Romazicon) 0.2 to 1 mg
b. Flumazenil (Romazicon) 2 to 10 mg
c. Naloxone (Narcan) 0.4 to 2 mg
d. Naloxone (Narcan) 4 to 20 mg - CORRECT ANSWER ANS: A
Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in
this situation. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.
A nurse is caring for a postoperative client who reports discomfort, but denies
serious pain and does not want medication. What action by the nurse is best to
promote comfort?
a. Assess the client's pain on a 0-to-10 scale.
b. Assist the client into a position of comfort.
c. Have the client sit up in a recliner.
d. Tell the client when pain medication is due. - CORRECT ANSWER ANS: B
Several nonpharmacologic comfort measures can help postoperative clients with
their pain, including distraction, music, massage, guided imagery, and positioning.
The nurse should help this client into a position of comfort considering the
, surgical procedure and position of any tubes or drains. Assessing the client's pain
is important but does not improve comfort. The client may be more
uncomfortable in a recliner. Letting the client know when pain medication can be
given next is important but does not improve comfort.
A nurse is preparing a client for discharge after surgery. The client needs to
change a large dressing and manage a drain at home. What instruction by the
nurse is most important?
a. "Be sure you keep all your postoperative appointments."
b. "Call your surgeon if you have any questions at home."
c. "Eat a diet high in protein, iron, zinc, and vitamin C."
d. "Wash your hands before touching the drain or dressing." - CORRECT ANSWER
ANS: D
All options are appropriate for the client being discharged after surgery. However,
for this client who is changing a dressing and managing a drain, infection control
is the priority. The nurse should instruct the client to wash hands often, including
before and after touching the dressing or drain.
An older adult has been transferred to the postoperative inpatient unit after
surgery. The family is concerned that the client is not waking up quickly and states
"She needs to get back to her old self!" What response by the nurse is best?
a. "Everyone comes out of surgery differently."
b. "Let's just give her some more time, okay?"
c. "She may have had a stroke during surgery."
d. "Sometimes older people take longer to wake up." - CORRECT ANSWER ANS: D
Due to age-related changes, it may take longer for an older adult to metabolize
anesthetic agents and pain medications, making it appear that they are taking too
long to wake up and return to their normal baseline cognitive status. The nurse
should educate the family on this possibility. While everyone does react
differently, this does not give the family any objective information. Saying "Let's
just give her more time, okay?" sounds patronizing and again does not provide
information. While an intraoperative stroke is a possibility, the nurse should
concentrate on the more common occurrence of older clients taking longer to
fully arouse and awake.
