[NR 226: Fundamentals of Patient Care - Surgical & Perioperative Nursing 2026
[Part I: Preoperative Nursing Care (Questions 1-6)]
Q1: A 68-year-old male with a history of atrial fibrillation is scheduled for an elective total knee
replacement in 5 days. His current medications include rivaroxaban 20 mg daily, metoprolol, and
atorvastatin. Based on current perioperative anticoagulation guidelines, which action should the nurse
prioritize during the preoperative medication reconciliation?
A. Continue rivaroxaban through the morning of surgery and administer with a sip of water. B. Hold
rivaroxaban for 48–72 hours prior to surgery based on renal function and bleeding risk. [CORRECT] C.
Initiate bridging therapy with enoxaparin 1 mg/kg subcutaneously twice daily beginning 3 days before
surgery. D. Discontinue metoprolol 24 hours before surgery to prevent intraoperative hypotension.
Correct Answer: B Rationale: For patients undergoing high bleeding-risk procedures such as total knee
replacement, factor Xa inhibitors like rivaroxaban should be held 48–72 hours preoperatively in patients
with normal renal function (CrCl >50 mL/min) to minimize residual anticoagulant effect and reduce
bleeding risk, with timing adjusted based on renal function.
Q2: A 72-year-old female with type 2 diabetes (HbA1c 8.2%), hypertension, and chronic kidney disease
(CrCl 28 mL/min) is scheduled for an open cholecystectomy. Her ASA physical status classification is III.
Which preoperative finding requires the nurse's immediate attention and communication to the
surgeon?
A. The patient's most recent blood pressure reading is 148/86 mmHg. B. The patient's fasting blood
glucose is 210 mg/dL on the morning of surgery. [CORRECT] C. The patient reports mild anxiety about
the surgical procedure. D. The patient has a documented allergy to shellfish.
Correct Answer: B Rationale: Perioperative hyperglycemia (typically >180–200 mg/dL) is associated with
increased risk of surgical site infection, impaired wound healing, and poor surgical outcomes; current
guidelines recommend optimizing glucose control before elective surgery, making this the priority
finding requiring immediate surgeon notification.
Q3: A 55-year-old male is scheduled for an elective inguinal hernia repair. During the preoperative
teaching session, the nurse reviews NPO guidelines. The patient states he ate a light breakfast of toast
and coffee 4 hours ago. Which response by the nurse is most appropriate?
, A. "You can proceed with surgery since toast and coffee are considered clear liquids." B. "The
anesthesiologist will need to be notified, as solid foods require at least 6–8 hours of NPO status before
general anesthesia." [CORRECT] C. "A light breakfast is acceptable 4 hours prior to surgery under
enhanced recovery protocols." D. "We will give you medication to speed up gastric emptying so surgery
can proceed on schedule."
Correct Answer: B Rationale: Current anesthesia guidelines require a minimum of 6–8 hours of NPO
status after ingestion of solid foods (including toast) to reduce the risk of aspiration during general
anesthesia; clear liquids are typically permitted up to 2 hours preoperatively, but solid foods require
longer gastric emptying time.
Q4: A 45-year-old female is scheduled for a laparoscopic hysterectomy. She takes warfarin 5 mg daily for
a mechanical mitral valve. Her INR is 2.8 on the day of preoperative testing (3 days before surgery).
Which preoperative medication management plan is most appropriate?
A. Continue warfarin at the current dose until the night before surgery. B. Hold warfarin immediately,
check INR daily, and begin bridging with therapeutic enoxaparin when INR falls below 2.5. [CORRECT] C.
Administer vitamin K 10 mg orally to rapidly reverse anticoagulation before surgery. D. Discontinue
warfarin and do not bridge, as the mechanical valve places her at low thrombotic risk.
Correct Answer: B Rationale: For patients with mechanical heart valves (high thrombotic risk)
undergoing elective surgery, warfarin should be discontinued 5 days preoperatively with daily INR
monitoring, and bridging anticoagulation with therapeutic low-molecular-weight heparin should be
initiated when the INR falls to 2.0 or below (or ≤2.5 for mechanical valve) to maintain
thromboprophylaxis while minimizing bleeding risk.
Q5: A 62-year-old male is scheduled for coronary artery bypass grafting (CABG). He currently takes
aspirin 81 mg daily and clopidogrel 75 mg daily following drug-eluting stent placement 8 weeks ago.
Which preoperative medication instruction is correct?
A. Discontinue both aspirin and clopidogrel 7 days before surgery to minimize bleeding risk. B. Continue
aspirin without interruption and hold clopidogrel for 5 days before surgery. [CORRECT] C. Continue both
medications through the morning of surgery to prevent stent thrombosis. D. Hold aspirin 7 days before
surgery and continue clopidogrel until 3 days before surgery.
Correct Answer: B Rationale: Current perioperative antiplatelet guidelines recommend continuing
aspirin without interruption for most surgical procedures, while clopidogrel should be withheld for 5–7
days preoperatively due to its irreversible platelet inhibition; this balances bleeding risk with thrombotic
risk, particularly in patients with recent stent placement.
[Part I: Preoperative Nursing Care (Questions 1-6)]
Q1: A 68-year-old male with a history of atrial fibrillation is scheduled for an elective total knee
replacement in 5 days. His current medications include rivaroxaban 20 mg daily, metoprolol, and
atorvastatin. Based on current perioperative anticoagulation guidelines, which action should the nurse
prioritize during the preoperative medication reconciliation?
A. Continue rivaroxaban through the morning of surgery and administer with a sip of water. B. Hold
rivaroxaban for 48–72 hours prior to surgery based on renal function and bleeding risk. [CORRECT] C.
Initiate bridging therapy with enoxaparin 1 mg/kg subcutaneously twice daily beginning 3 days before
surgery. D. Discontinue metoprolol 24 hours before surgery to prevent intraoperative hypotension.
Correct Answer: B Rationale: For patients undergoing high bleeding-risk procedures such as total knee
replacement, factor Xa inhibitors like rivaroxaban should be held 48–72 hours preoperatively in patients
with normal renal function (CrCl >50 mL/min) to minimize residual anticoagulant effect and reduce
bleeding risk, with timing adjusted based on renal function.
Q2: A 72-year-old female with type 2 diabetes (HbA1c 8.2%), hypertension, and chronic kidney disease
(CrCl 28 mL/min) is scheduled for an open cholecystectomy. Her ASA physical status classification is III.
Which preoperative finding requires the nurse's immediate attention and communication to the
surgeon?
A. The patient's most recent blood pressure reading is 148/86 mmHg. B. The patient's fasting blood
glucose is 210 mg/dL on the morning of surgery. [CORRECT] C. The patient reports mild anxiety about
the surgical procedure. D. The patient has a documented allergy to shellfish.
Correct Answer: B Rationale: Perioperative hyperglycemia (typically >180–200 mg/dL) is associated with
increased risk of surgical site infection, impaired wound healing, and poor surgical outcomes; current
guidelines recommend optimizing glucose control before elective surgery, making this the priority
finding requiring immediate surgeon notification.
Q3: A 55-year-old male is scheduled for an elective inguinal hernia repair. During the preoperative
teaching session, the nurse reviews NPO guidelines. The patient states he ate a light breakfast of toast
and coffee 4 hours ago. Which response by the nurse is most appropriate?
, A. "You can proceed with surgery since toast and coffee are considered clear liquids." B. "The
anesthesiologist will need to be notified, as solid foods require at least 6–8 hours of NPO status before
general anesthesia." [CORRECT] C. "A light breakfast is acceptable 4 hours prior to surgery under
enhanced recovery protocols." D. "We will give you medication to speed up gastric emptying so surgery
can proceed on schedule."
Correct Answer: B Rationale: Current anesthesia guidelines require a minimum of 6–8 hours of NPO
status after ingestion of solid foods (including toast) to reduce the risk of aspiration during general
anesthesia; clear liquids are typically permitted up to 2 hours preoperatively, but solid foods require
longer gastric emptying time.
Q4: A 45-year-old female is scheduled for a laparoscopic hysterectomy. She takes warfarin 5 mg daily for
a mechanical mitral valve. Her INR is 2.8 on the day of preoperative testing (3 days before surgery).
Which preoperative medication management plan is most appropriate?
A. Continue warfarin at the current dose until the night before surgery. B. Hold warfarin immediately,
check INR daily, and begin bridging with therapeutic enoxaparin when INR falls below 2.5. [CORRECT] C.
Administer vitamin K 10 mg orally to rapidly reverse anticoagulation before surgery. D. Discontinue
warfarin and do not bridge, as the mechanical valve places her at low thrombotic risk.
Correct Answer: B Rationale: For patients with mechanical heart valves (high thrombotic risk)
undergoing elective surgery, warfarin should be discontinued 5 days preoperatively with daily INR
monitoring, and bridging anticoagulation with therapeutic low-molecular-weight heparin should be
initiated when the INR falls to 2.0 or below (or ≤2.5 for mechanical valve) to maintain
thromboprophylaxis while minimizing bleeding risk.
Q5: A 62-year-old male is scheduled for coronary artery bypass grafting (CABG). He currently takes
aspirin 81 mg daily and clopidogrel 75 mg daily following drug-eluting stent placement 8 weeks ago.
Which preoperative medication instruction is correct?
A. Discontinue both aspirin and clopidogrel 7 days before surgery to minimize bleeding risk. B. Continue
aspirin without interruption and hold clopidogrel for 5 days before surgery. [CORRECT] C. Continue both
medications through the morning of surgery to prevent stent thrombosis. D. Hold aspirin 7 days before
surgery and continue clopidogrel until 3 days before surgery.
Correct Answer: B Rationale: Current perioperative antiplatelet guidelines recommend continuing
aspirin without interruption for most surgical procedures, while clopidogrel should be withheld for 5–7
days preoperatively due to its irreversible platelet inhibition; this balances bleeding risk with thrombotic
risk, particularly in patients with recent stent placement.
