NR 325 Adult Health II (Chamberlain
University)
Exam Comprehensive Study Guide — 210 Questions, Answers & Rationales
1. What is the priority nursing responsibility during the preoperative phase regarding informed
consent?
Correct Answer: Verify that informed consent has been obtained by the surgeon and that
the patient demonstrates understanding of the procedure, risks, benefits, and
alternatives
Rationale: While the surgeon is responsible for obtaining truly informed consent, the nurse's role
includes witnessing the signature, verifying the patient's understanding, and notifying the
surgeon if the patient expresses confusion or wishes to withdraw consent before proceeding.
2. What is the priority nursing assessment during the preoperative phase regarding a patient's
medication history?
Correct Answer: Identify all current medications, including herbal supplements and
over-the-counter drugs, and clarify which should be held versus continued before
surgery
Rationale: Certain medications (e.g., anticoagulants, some herbal supplements that increase
bleeding risk) may need to be held before surgery, while others (e.g., some cardiac or antiseizure
medications) should be continued; thorough medication reconciliation prevents perioperative
complications from unexpected drug interactions or effects.
3. Why is preoperative fasting (NPO status) important before a scheduled surgical procedure
requiring general anesthesia?
Correct Answer: To reduce the risk of pulmonary aspiration of gastric contents during
induction of anesthesia
Rationale: General anesthesia suppresses protective airway reflexes, increasing the risk that any
gastric contents present could be aspirated into the lungs; standard NPO guidelines (e.g., 8 hours
for a heavy meal, 2 hours for clear liquids) are designed to minimize gastric volume and this
associated risk.
4. What is the priority nursing intervention immediately preoperatively regarding patient
identification and surgical site verification?
1
, Correct Answer: Participate in the surgical time-out procedure, verifying correct patient
identity, correct procedure, and correct surgical site
Rationale: The surgical time-out is a critical safety checkpoint designed to prevent wrong-
patient, wrong-procedure, or wrong-site surgery, requiring active verbal confirmation from all
members of the surgical team immediately before the procedure begins.
5. What is the priority nursing assessment in the immediate postoperative period (PACU) regarding
airway and breathing?
Correct Answer: Assess airway patency, respiratory rate and depth, and oxygen
saturation, as airway compromise and respiratory depression are the most immediate
life-threatening risks following anesthesia
Rationale: Residual anesthesia effects can impair airway reflexes and depress respiratory drive;
prioritizing airway and breathing assessment first, following the ABC framework, addresses the
most immediately life-threatening potential complications in the early recovery period.
6. What is the priority nursing intervention for a postoperative patient who is difficult to arouse
with shallow, slow respirations in the PACU?
Correct Answer: Stimulate the patient, ensure a patent airway, and notify the anesthesia
provider, anticipating possible reversal agent administration
Rationale: This presentation suggests residual anesthesia or opioid-related respiratory
depression; prompt recognition and intervention, including possible administration of a reversal
agent, is critical to prevent progression to respiratory arrest.
7. What is the priority nursing assessment for a postoperative patient regarding surgical site
bleeding?
Correct Answer: Regularly assess the surgical dressing and any drains for the amount,
color, and characteristics of drainage, and monitor for signs of hypovolemia
Rationale: Early identification of excessive bleeding allows for prompt intervention; monitoring
vital signs alongside dressing/drain assessment helps distinguish expected postoperative
drainage from a developing hemorrhagic complication requiring surgical re-exploration.
8. What is the priority nursing intervention to prevent postoperative atelectasis and pneumonia?
Correct Answer: Encourage use of an incentive spirometer, deep breathing and coughing
exercises, and early ambulation
Rationale: These interventions promote full lung expansion and secretion clearance,
counteracting the shallow breathing pattern common after surgery due to pain, sedation, and
positioning, thereby reducing the risk of atelectasis and subsequent pneumonia.
2
,9. Why is early ambulation prioritized in the postoperative period, particularly for prevention of
venous thromboembolism?
Correct Answer: Ambulation promotes venous return and reduces blood stasis in the
lower extremities, one of the key contributing factors (Virchow's triad) to deep vein
thrombosis formation
Rationale: Postoperative immobility significantly increases DVT risk due to venous stasis;
combined with mechanical prophylaxis (sequential compression devices) and, when indicated,
pharmacologic prophylaxis, early ambulation is a cornerstone nursing intervention for VTE
prevention.
10. What is the priority nursing assessment for a patient in the first 24-48 hours after abdominal
surgery regarding gastrointestinal function?
Correct Answer: Monitor for the return of bowel sounds and passage of flatus, indicating
resolution of postoperative ileus
Rationale: Postoperative ileus (temporary bowel motility impairment) is expected after
abdominal surgery, particularly with manipulation of the bowel; monitoring for the return of
bowel sounds and flatus passage helps determine when it is safe to advance the patient's diet.
11. A postoperative patient suddenly reports feeling like something 'gave way' in their incision, and
the wound edges separate with visible viscera protruding. What is the priority nursing action?
Correct Answer: Cover the exposed viscera with a sterile saline-soaked dressing, keep
the patient NPO and positioned to reduce tension on the wound, and notify the surgeon
immediately
Rationale: This describes wound evisceration, a surgical emergency; covering the exposed organs
with sterile, moist dressings prevents further tissue drying and contamination while awaiting
emergent surgical intervention, and positioning (often with knees bent) reduces further tension
on the wound.
12. What is the priority nursing intervention for a patient experiencing postoperative nausea and
vomiting?
Correct Answer: Administer prescribed antiemetic medication and position the patient
to reduce aspiration risk
Rationale: Postoperative nausea and vomiting is common due to anesthesia effects, and prompt
treatment not only improves patient comfort but reduces the risk of aspiration, wound dehiscence
from forceful retching, and delayed return to normal oral intake.
3
, 13. What is the priority nursing assessment regarding pain management in the immediate
postoperative period?
Correct Answer: Assess pain using a validated pain scale regularly and provide analgesia
proactively rather than waiting for pain to become severe
Rationale: Proactive, scheduled pain assessment and management improves patient comfort,
facilitates participation in important recovery activities (ambulation, deep breathing, coughing),
and helps prevent the development of harder-to-control severe pain.
14. What is the significance of a low urine output (less than 30 mL/hr) in the immediate
postoperative period?
Correct Answer: It may indicate hypovolemia, inadequate fluid resuscitation, or acute
kidney injury, requiring further assessment and possible intervention
Rationale: Adequate urine output reflects adequate renal perfusion; postoperative oliguria
requires prompt evaluation of fluid status and possible causes, as inadequate perfusion can lead
to acute kidney injury if not addressed.
15. What is malignant hyperthermia, and what is the priority intervention if it develops during or
after surgery?
Correct Answer: A life-threatening hypermetabolic reaction to certain anesthetic agents
in genetically susceptible individuals; the priority intervention is immediate
discontinuation of the triggering agent and administration of dantrolene
Rationale: Malignant hyperthermia causes a rapid, dangerous rise in body temperature, muscle
rigidity, and metabolic acidosis; rapid recognition and treatment with dantrolene are critical to
prevent severe complications including cardiac arrest and death.
16. What is the priority nursing consideration for a patient with a Jackson-Pratt or Hemovac drain
postoperatively?
Correct Answer: Regularly empty and measure drainage output, and maintain
appropriate compression of the bulb reservoir to preserve the suction needed for
effective drainage
Rationale: These drains rely on gentle suction created by compressing the bulb reservoir to draw
fluid away from the surgical site; regular emptying maintains this suction and allows accurate
tracking of drainage volume and characteristics, important for assessing postoperative recovery.
17. What is the priority nursing teaching for a patient being discharged after surgery regarding
signs of surgical site infection?
4
University)
Exam Comprehensive Study Guide — 210 Questions, Answers & Rationales
1. What is the priority nursing responsibility during the preoperative phase regarding informed
consent?
Correct Answer: Verify that informed consent has been obtained by the surgeon and that
the patient demonstrates understanding of the procedure, risks, benefits, and
alternatives
Rationale: While the surgeon is responsible for obtaining truly informed consent, the nurse's role
includes witnessing the signature, verifying the patient's understanding, and notifying the
surgeon if the patient expresses confusion or wishes to withdraw consent before proceeding.
2. What is the priority nursing assessment during the preoperative phase regarding a patient's
medication history?
Correct Answer: Identify all current medications, including herbal supplements and
over-the-counter drugs, and clarify which should be held versus continued before
surgery
Rationale: Certain medications (e.g., anticoagulants, some herbal supplements that increase
bleeding risk) may need to be held before surgery, while others (e.g., some cardiac or antiseizure
medications) should be continued; thorough medication reconciliation prevents perioperative
complications from unexpected drug interactions or effects.
3. Why is preoperative fasting (NPO status) important before a scheduled surgical procedure
requiring general anesthesia?
Correct Answer: To reduce the risk of pulmonary aspiration of gastric contents during
induction of anesthesia
Rationale: General anesthesia suppresses protective airway reflexes, increasing the risk that any
gastric contents present could be aspirated into the lungs; standard NPO guidelines (e.g., 8 hours
for a heavy meal, 2 hours for clear liquids) are designed to minimize gastric volume and this
associated risk.
4. What is the priority nursing intervention immediately preoperatively regarding patient
identification and surgical site verification?
1
, Correct Answer: Participate in the surgical time-out procedure, verifying correct patient
identity, correct procedure, and correct surgical site
Rationale: The surgical time-out is a critical safety checkpoint designed to prevent wrong-
patient, wrong-procedure, or wrong-site surgery, requiring active verbal confirmation from all
members of the surgical team immediately before the procedure begins.
5. What is the priority nursing assessment in the immediate postoperative period (PACU) regarding
airway and breathing?
Correct Answer: Assess airway patency, respiratory rate and depth, and oxygen
saturation, as airway compromise and respiratory depression are the most immediate
life-threatening risks following anesthesia
Rationale: Residual anesthesia effects can impair airway reflexes and depress respiratory drive;
prioritizing airway and breathing assessment first, following the ABC framework, addresses the
most immediately life-threatening potential complications in the early recovery period.
6. What is the priority nursing intervention for a postoperative patient who is difficult to arouse
with shallow, slow respirations in the PACU?
Correct Answer: Stimulate the patient, ensure a patent airway, and notify the anesthesia
provider, anticipating possible reversal agent administration
Rationale: This presentation suggests residual anesthesia or opioid-related respiratory
depression; prompt recognition and intervention, including possible administration of a reversal
agent, is critical to prevent progression to respiratory arrest.
7. What is the priority nursing assessment for a postoperative patient regarding surgical site
bleeding?
Correct Answer: Regularly assess the surgical dressing and any drains for the amount,
color, and characteristics of drainage, and monitor for signs of hypovolemia
Rationale: Early identification of excessive bleeding allows for prompt intervention; monitoring
vital signs alongside dressing/drain assessment helps distinguish expected postoperative
drainage from a developing hemorrhagic complication requiring surgical re-exploration.
8. What is the priority nursing intervention to prevent postoperative atelectasis and pneumonia?
Correct Answer: Encourage use of an incentive spirometer, deep breathing and coughing
exercises, and early ambulation
Rationale: These interventions promote full lung expansion and secretion clearance,
counteracting the shallow breathing pattern common after surgery due to pain, sedation, and
positioning, thereby reducing the risk of atelectasis and subsequent pneumonia.
2
,9. Why is early ambulation prioritized in the postoperative period, particularly for prevention of
venous thromboembolism?
Correct Answer: Ambulation promotes venous return and reduces blood stasis in the
lower extremities, one of the key contributing factors (Virchow's triad) to deep vein
thrombosis formation
Rationale: Postoperative immobility significantly increases DVT risk due to venous stasis;
combined with mechanical prophylaxis (sequential compression devices) and, when indicated,
pharmacologic prophylaxis, early ambulation is a cornerstone nursing intervention for VTE
prevention.
10. What is the priority nursing assessment for a patient in the first 24-48 hours after abdominal
surgery regarding gastrointestinal function?
Correct Answer: Monitor for the return of bowel sounds and passage of flatus, indicating
resolution of postoperative ileus
Rationale: Postoperative ileus (temporary bowel motility impairment) is expected after
abdominal surgery, particularly with manipulation of the bowel; monitoring for the return of
bowel sounds and flatus passage helps determine when it is safe to advance the patient's diet.
11. A postoperative patient suddenly reports feeling like something 'gave way' in their incision, and
the wound edges separate with visible viscera protruding. What is the priority nursing action?
Correct Answer: Cover the exposed viscera with a sterile saline-soaked dressing, keep
the patient NPO and positioned to reduce tension on the wound, and notify the surgeon
immediately
Rationale: This describes wound evisceration, a surgical emergency; covering the exposed organs
with sterile, moist dressings prevents further tissue drying and contamination while awaiting
emergent surgical intervention, and positioning (often with knees bent) reduces further tension
on the wound.
12. What is the priority nursing intervention for a patient experiencing postoperative nausea and
vomiting?
Correct Answer: Administer prescribed antiemetic medication and position the patient
to reduce aspiration risk
Rationale: Postoperative nausea and vomiting is common due to anesthesia effects, and prompt
treatment not only improves patient comfort but reduces the risk of aspiration, wound dehiscence
from forceful retching, and delayed return to normal oral intake.
3
, 13. What is the priority nursing assessment regarding pain management in the immediate
postoperative period?
Correct Answer: Assess pain using a validated pain scale regularly and provide analgesia
proactively rather than waiting for pain to become severe
Rationale: Proactive, scheduled pain assessment and management improves patient comfort,
facilitates participation in important recovery activities (ambulation, deep breathing, coughing),
and helps prevent the development of harder-to-control severe pain.
14. What is the significance of a low urine output (less than 30 mL/hr) in the immediate
postoperative period?
Correct Answer: It may indicate hypovolemia, inadequate fluid resuscitation, or acute
kidney injury, requiring further assessment and possible intervention
Rationale: Adequate urine output reflects adequate renal perfusion; postoperative oliguria
requires prompt evaluation of fluid status and possible causes, as inadequate perfusion can lead
to acute kidney injury if not addressed.
15. What is malignant hyperthermia, and what is the priority intervention if it develops during or
after surgery?
Correct Answer: A life-threatening hypermetabolic reaction to certain anesthetic agents
in genetically susceptible individuals; the priority intervention is immediate
discontinuation of the triggering agent and administration of dantrolene
Rationale: Malignant hyperthermia causes a rapid, dangerous rise in body temperature, muscle
rigidity, and metabolic acidosis; rapid recognition and treatment with dantrolene are critical to
prevent severe complications including cardiac arrest and death.
16. What is the priority nursing consideration for a patient with a Jackson-Pratt or Hemovac drain
postoperatively?
Correct Answer: Regularly empty and measure drainage output, and maintain
appropriate compression of the bulb reservoir to preserve the suction needed for
effective drainage
Rationale: These drains rely on gentle suction created by compressing the bulb reservoir to draw
fluid away from the surgical site; regular emptying maintains this suction and allows accurate
tracking of drainage volume and characteristics, important for assessing postoperative recovery.
17. What is the priority nursing teaching for a patient being discharged after surgery regarding
signs of surgical site infection?
4
