RNSG 1517 Protection & Regulation
EXAM 5 | Complete Questions with
Correct Answers and Detailed Rationales
- Latest Update 2026
Question 1
The nurse is caring for an older client during the intraoperative stage. The
anesthesia process has already begun and the nurse has already removed the
dentures, eyeglasses, and hearing aids. After the nurse performs these actions,
what would be the FIRST intraoperative nursing intervention?
A) Cover the client's head and feet
B) Use a small pillow under the client's head
C) Pad bony prominences to prevent pressure sores
D) Follow aseptic technique
Correct ,,,answer,,,: B
Rationale: After removing dentures, eyeglasses, and hearing aids, the nurse should
first use a small pillow under the client's head for proper positioning and airway
maintenance.
,Question 2
A client received intrathecal morphine intraoperatively for pain control. What
should the nurse include as part of the client's initial 24-hour postoperative care?
A) Monitoring respiratory rate hourly
B) Assessing the client for tachycardia
C) Administering naloxone every 3 to 4 hours
D) Observing for signs of CNS excitement
Correct ,,,answer,,,: A
Rationale: Intrathecal morphine can cause respiratory depression, so monitoring
respiratory rate hourly is essential during the first 24 hours postoperatively.
Question 3
The nurse suspects that an intraoperative client has a distended bladder. Which
method is correct to assess for this condition?
A) Inspect and palpate in the epigastric region
B) Auscultate and percuss in the inguinal areas
C) Percuss and palpate in the hypogastric region
D) Percuss and palpate bilaterally in the lumbar areas
Correct ,,,answer,,,: C
Rationale: To detect a distended bladder, percussion and palpation should be
performed over the hypogastric region of the abdomen.
,Question 4
Which of the following is a priority nursing intervention for a postoperative client at
risk for venous thromboembolism (VTE)?
A) Administer oral anticoagulants immediately
B) Apply sequential compression devices (SCDs)
C) Keep the client on strict bed rest
D) Massage the lower extremities
Correct ,,,answer,,,: B
Rationale: Sequential compression devices help prevent venous stasis and reduce
the risk of VTE by promoting venous return from the lower extremities.
Question 5
A client with a suspected deep vein thrombosis (DVT) reports sudden shortness of
breath and chest pain. What is the nurse's priority action?
A) Administer oxygen and notify the healthcare provider
B) Notify the rapid response team immediately
C) Apply warm compresses to the affected leg
D) Encourage deep breathing exercises
Correct ,,,answer,,,: B
Rationale: Sudden shortness of breath and chest pain in a client with suspected
DVT may indicate a pulmonary embolism, which is a life-threatening emergency
requiring immediate intervention.
, Question 6
What is the primary purpose of padding bony prominences during intraoperative
positioning?
A) To improve surgical access
B) To prevent pressure ulcers
C) To maintain body temperature
D) To prevent shearing forces
Correct ,,,answer,,,: B
Rationale: Padding bony prominences helps distribute pressure evenly and
prevents the development of pressure ulcers during prolonged surgical procedures.
Question 7
A postoperative client has a distended bladder. Which assessment finding would
the nurse most likely observe?
A) Hypertension and tachycardia
B) Suprapubic fullness and restlessness
C) Decreased urine output with dark amber color
D) Flank pain and fever
Correct ,,,answer,,,: B
Rationale: A distended bladder presents with suprapubic fullness, restlessness,
and sometimes decreased urine output. Percussion and palpation in the
hypogastric region can confirm the finding.
EXAM 5 | Complete Questions with
Correct Answers and Detailed Rationales
- Latest Update 2026
Question 1
The nurse is caring for an older client during the intraoperative stage. The
anesthesia process has already begun and the nurse has already removed the
dentures, eyeglasses, and hearing aids. After the nurse performs these actions,
what would be the FIRST intraoperative nursing intervention?
A) Cover the client's head and feet
B) Use a small pillow under the client's head
C) Pad bony prominences to prevent pressure sores
D) Follow aseptic technique
Correct ,,,answer,,,: B
Rationale: After removing dentures, eyeglasses, and hearing aids, the nurse should
first use a small pillow under the client's head for proper positioning and airway
maintenance.
,Question 2
A client received intrathecal morphine intraoperatively for pain control. What
should the nurse include as part of the client's initial 24-hour postoperative care?
A) Monitoring respiratory rate hourly
B) Assessing the client for tachycardia
C) Administering naloxone every 3 to 4 hours
D) Observing for signs of CNS excitement
Correct ,,,answer,,,: A
Rationale: Intrathecal morphine can cause respiratory depression, so monitoring
respiratory rate hourly is essential during the first 24 hours postoperatively.
Question 3
The nurse suspects that an intraoperative client has a distended bladder. Which
method is correct to assess for this condition?
A) Inspect and palpate in the epigastric region
B) Auscultate and percuss in the inguinal areas
C) Percuss and palpate in the hypogastric region
D) Percuss and palpate bilaterally in the lumbar areas
Correct ,,,answer,,,: C
Rationale: To detect a distended bladder, percussion and palpation should be
performed over the hypogastric region of the abdomen.
,Question 4
Which of the following is a priority nursing intervention for a postoperative client at
risk for venous thromboembolism (VTE)?
A) Administer oral anticoagulants immediately
B) Apply sequential compression devices (SCDs)
C) Keep the client on strict bed rest
D) Massage the lower extremities
Correct ,,,answer,,,: B
Rationale: Sequential compression devices help prevent venous stasis and reduce
the risk of VTE by promoting venous return from the lower extremities.
Question 5
A client with a suspected deep vein thrombosis (DVT) reports sudden shortness of
breath and chest pain. What is the nurse's priority action?
A) Administer oxygen and notify the healthcare provider
B) Notify the rapid response team immediately
C) Apply warm compresses to the affected leg
D) Encourage deep breathing exercises
Correct ,,,answer,,,: B
Rationale: Sudden shortness of breath and chest pain in a client with suspected
DVT may indicate a pulmonary embolism, which is a life-threatening emergency
requiring immediate intervention.
, Question 6
What is the primary purpose of padding bony prominences during intraoperative
positioning?
A) To improve surgical access
B) To prevent pressure ulcers
C) To maintain body temperature
D) To prevent shearing forces
Correct ,,,answer,,,: B
Rationale: Padding bony prominences helps distribute pressure evenly and
prevents the development of pressure ulcers during prolonged surgical procedures.
Question 7
A postoperative client has a distended bladder. Which assessment finding would
the nurse most likely observe?
A) Hypertension and tachycardia
B) Suprapubic fullness and restlessness
C) Decreased urine output with dark amber color
D) Flank pain and fever
Correct ,,,answer,,,: B
Rationale: A distended bladder presents with suprapubic fullness, restlessness,
and sometimes decreased urine output. Percussion and palpation in the
hypogastric region can confirm the finding.
