Saunders Comprehensive Review for the
NCLEX-RN Exam Pre-op, Intra-op,
Post-op
A client is admitted to a surgical unit postoperatively with a wound drain in place.
Which actions should the nurse avoid in the care of the drain?
1. Check the drain for patency.
2. Observe bright red bloody drainage.
3. Curl the drain tightly and tape it firmly to the body.
4. Maintain aseptic technique when emptying the drain. - ANS-3. Curl the drain
tightly and tape it firmly to the body.
Rationale: A postoperative drain should not be curled tightly or obstructed in any
way. This could prevent the drain from functioning properly. The nurse should check
the tube or drain for patency to provide an exit for the fluid or blood to promote
healing. The nurse must use aseptic technique for emptying the drainage container
or changing the dressing to avoid contamination of the wound. The nurse should
monitor the drainage characteristics. Usually, the drainage from the wound is pale,
red, and watery. Active bleeding will be bright red.
Test-Taking Strategy: Note the strategy word "avoid". Remember that surgical drains
need to remain patent so that accumulated secretions can escape from the wound
bed. If you had difficulty with this question, review nursing care for the client with a
surgical drain.
\A client who has undergone preadmission testing has had blood drawn for serum
laboratory studies, including a complete blood count, coagulation studies, and
electrolytes and creatinine levels. Which of the following laboratory results should be
reported to the surgeon's office by the nurse, knowing that it could cause surgery to
be postponed?
1. Sodium, 141 mEq/L
2. Hemoglobin, 8.0 g/dL
3. Platelets, 210,000/mm3
4. Serum creatinine, 0.8 mg/dL - ANS-2. Hemoglobin, 8.0 g/dL
Rationale: Routine screening tests include a complete blood count, serum electrolyte
analysis, coagulation studies, and a serum creatinine test. The complete blood count
includes the hemoglobin analysis. All these values are within normal range except
for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be
postponed by the surgeon.
, Test-Taking Strategy: Focus on the subject , an abnormal laboratory result that
needs to be reported. Use knowledge of the normal laboratory values to assist in
answering correctly. The hemoglobin value is the only incorrect laboratory finding.
Review these laboratory values if you had difficulty answering this question.
\A client with a perforated gastric ulcer is scheduled for surgery. The client cannot
sign the operative consent form because of sedation from opioid analgesics that
have been administered. The nurse should take which appropriate action in the care
of this client?
1. Obtain a court order for the surgery.
2. Send the client to surgery without the consent form being signed.
3. Have the hospital chaplain sign the informed consent immediately.
4. Obtain telephone consent from a family member, following agency policy. - ANS-4.
Obtain telephone consent from a family member, following agency policy.
Rationale: Every effort should be made to obtain permission from a responsible
family member to perform surgery if the client is unable to sign the consent form. A
telephone consent must be witnessed by two persons who hear the family member's
oral consent. The two witnesses then sign the consent with the name of the family
member, noting that an oral consent was obtained. Consent is not informed if it is
obtained from a client who is confused, unconscious, mentally incompetent, or under
the influence of sedatives. In an emergency, a client may be unable to sign and
family members may not be available. In this situation, a health care provider is
permitted legally to perform surgery without consent, but in this case it is not an
emergency. Options 1 and 3 are not appropriate in this situation. Also, agency
policies regarding informed consent should always be followed.
Test-Taking Strategy: Note the strategic words "most appropriate". Focus on the data
in the question. Eliminate 1 and 3 first. Option 1 will delay necessary surgery and
option 3 is inappropriate. Select the correct option over option 2 because it is the
most appropriate of the options presented and it is legally acceptable to obtain a
telephone permission from a family member if it is witnessed by two persons. Review
the implications surrounding informed consent if you had difficulty with this question.
\A nurse assesses a client's surgical incision for signs of infection. Which finding by
the nurse would be interpreted as a normal finding at the surgical site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm, tender skin - ANS-2. Serous drainage
Rationale: Serous drainage is an expected finding at a surgical site. The other
options indicate signs of wound infection. Signs and symptoms of infection include
warm, red, and tender skin around the incision. Wound infection usually appears 3 to
6 days after surgery. The client also may have a fever and chills. Purulent material
NCLEX-RN Exam Pre-op, Intra-op,
Post-op
A client is admitted to a surgical unit postoperatively with a wound drain in place.
Which actions should the nurse avoid in the care of the drain?
1. Check the drain for patency.
2. Observe bright red bloody drainage.
3. Curl the drain tightly and tape it firmly to the body.
4. Maintain aseptic technique when emptying the drain. - ANS-3. Curl the drain
tightly and tape it firmly to the body.
Rationale: A postoperative drain should not be curled tightly or obstructed in any
way. This could prevent the drain from functioning properly. The nurse should check
the tube or drain for patency to provide an exit for the fluid or blood to promote
healing. The nurse must use aseptic technique for emptying the drainage container
or changing the dressing to avoid contamination of the wound. The nurse should
monitor the drainage characteristics. Usually, the drainage from the wound is pale,
red, and watery. Active bleeding will be bright red.
Test-Taking Strategy: Note the strategy word "avoid". Remember that surgical drains
need to remain patent so that accumulated secretions can escape from the wound
bed. If you had difficulty with this question, review nursing care for the client with a
surgical drain.
\A client who has undergone preadmission testing has had blood drawn for serum
laboratory studies, including a complete blood count, coagulation studies, and
electrolytes and creatinine levels. Which of the following laboratory results should be
reported to the surgeon's office by the nurse, knowing that it could cause surgery to
be postponed?
1. Sodium, 141 mEq/L
2. Hemoglobin, 8.0 g/dL
3. Platelets, 210,000/mm3
4. Serum creatinine, 0.8 mg/dL - ANS-2. Hemoglobin, 8.0 g/dL
Rationale: Routine screening tests include a complete blood count, serum electrolyte
analysis, coagulation studies, and a serum creatinine test. The complete blood count
includes the hemoglobin analysis. All these values are within normal range except
for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be
postponed by the surgeon.
, Test-Taking Strategy: Focus on the subject , an abnormal laboratory result that
needs to be reported. Use knowledge of the normal laboratory values to assist in
answering correctly. The hemoglobin value is the only incorrect laboratory finding.
Review these laboratory values if you had difficulty answering this question.
\A client with a perforated gastric ulcer is scheduled for surgery. The client cannot
sign the operative consent form because of sedation from opioid analgesics that
have been administered. The nurse should take which appropriate action in the care
of this client?
1. Obtain a court order for the surgery.
2. Send the client to surgery without the consent form being signed.
3. Have the hospital chaplain sign the informed consent immediately.
4. Obtain telephone consent from a family member, following agency policy. - ANS-4.
Obtain telephone consent from a family member, following agency policy.
Rationale: Every effort should be made to obtain permission from a responsible
family member to perform surgery if the client is unable to sign the consent form. A
telephone consent must be witnessed by two persons who hear the family member's
oral consent. The two witnesses then sign the consent with the name of the family
member, noting that an oral consent was obtained. Consent is not informed if it is
obtained from a client who is confused, unconscious, mentally incompetent, or under
the influence of sedatives. In an emergency, a client may be unable to sign and
family members may not be available. In this situation, a health care provider is
permitted legally to perform surgery without consent, but in this case it is not an
emergency. Options 1 and 3 are not appropriate in this situation. Also, agency
policies regarding informed consent should always be followed.
Test-Taking Strategy: Note the strategic words "most appropriate". Focus on the data
in the question. Eliminate 1 and 3 first. Option 1 will delay necessary surgery and
option 3 is inappropriate. Select the correct option over option 2 because it is the
most appropriate of the options presented and it is legally acceptable to obtain a
telephone permission from a family member if it is witnessed by two persons. Review
the implications surrounding informed consent if you had difficulty with this question.
\A nurse assesses a client's surgical incision for signs of infection. Which finding by
the nurse would be interpreted as a normal finding at the surgical site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm, tender skin - ANS-2. Serous drainage
Rationale: Serous drainage is an expected finding at a surgical site. The other
options indicate signs of wound infection. Signs and symptoms of infection include
warm, red, and tender skin around the incision. Wound infection usually appears 3 to
6 days after surgery. The client also may have a fever and chills. Purulent material
