NUR 124 Final Practice Test
The nurse is preparing a client for surgery. Which of the following items on the client's presurgery lab
results would indicate a need to contact the surgeon?
a) Platelet count of 325,000 mm3
b) Total cholesterol of 325 mg/dL
c) Blood urea nitrogen (BUN) 17 mg/dL
d) Hemoglobin 9.5 g/dL ANS: d) Hemoglobin 9.5 g/dL
The hemoglobin level is low, and the nurse needs to make sure the surgeon has the most recent
laboratory values before surgery. This client may need a transfusion before surgery. The cholesterol is
elevated but is not a concern before surgery. The platelets and the BUN are within normal limits.
(Potter, Perry, 7 ed., pp. 1376-1377.)
In the recovery room, the postoperative client suddenly becomes restless with circumoral cyanosis.
What is the first nursing action?
a) Begin administration of oxygen through a nasal cannula.
b) Call for assistance.
c) Reposition the head and determine patency of airway.
d) Insert an oral airway and suction the nasopharynx. ANS: c) Reposition the head and determine
patency of airway.
It is important to determine whether the airway is patent and whether the client is breathing. If a
significant amount of mucus and gurgling are noted in the upper airway, the client should be suctioned.
Insertion of an oral airway may be necessary to maintain an open airway, but the airway must be
assessed before determining a course of action. Inserting an airway will not solve the problem if the
client is not breathing. (Lewis, Dirksen, Heitkemper et al, 8 ed., pp. 366-368.)
,The nurse is preparing the preoperative client for surgery. Which of the following statements indicate to
the nurse that the client is knowledgeable about his impending surgery? Select all that apply.
a) "After surgery, I will need to wear the pneumatic compression device while sitting in the chair."
b) "The skin prep area is going to be longer and wider than the anticipated incision."
c) "I cannot have anything to drink or eat after midnight on the night before the surgery."
d) "To ensure my safety, a time-out for identification will be conducted in the operating room before
surgery."
e) "I will be given the consent form, and I will sign it after I get to the operating room." ANS: b, c, d
Having the skin prep area being longer and wider than the actual incision, maintaining NPO status after
midnight, and performing the time-out identification indicate a correct understanding of the
preoperative teaching. The pneumatic compression device is worn during bed rest and is removed when
the client is out of bed or ambulating. The informed consent document should be signed before
preoperative medication administration and before the client enters the operating room. Part of safety
standards is to initiate a time-out in the operating room before the surgery is started. (Lewis, Dirksen,
Heitkemper, et al, 8 ed., pp. 341-343.)
A client is scheduled for major surgery. What is most important for the nurse to do before surgery?
a) Remove all jewelry or tape wedding rings.
b) Verify that all laboratory work is complete.
c) Inform family or next of kin of recovery procedure.
d) Check that consent forms are signed. ANS: d) Check that consent forms are signed.
Consent forms must be signed by the client, family, or guardian with medical power of attorney before
any procedure can be done. Consent forms also must be signed before the client receives any narcotics
or medications that would affect his reasoning. These medications are frequently in the preoperative
medications ordered. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 344-346.)
,The nurse is caring for a first-day postoperative surgical client. Prioritize the client's desired dietary
progression by numbering the following from 1 to 4 (with 1 being the first step and 4 being the last
step).
_Full liquid
_NPO
_Clear liquid
_Soft ANS: 1) NPO
2) Clear liquid
3) Full liquid
4) Soft
The client's status is NPO immediately after surgery. Desired diet progression advances next to clear
liquid. Desired diet progression then advances to full liquid. Desired diet progression next advances to a
soft diet and then finally to a regular diet as tolerated by the client. (Potter, Perry, 7 ed., pp. 1404-1405.)
A postoperative patient receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the
foods on the client's tray, what would the nurse anticipate the client's current diet order to be?
a) Bland diet
b) Soft diet
c) Full liquid diet
d) Regular diet ANS: c) Full liquid diet
A full liquid diet includes liquids, as well as foods that are liquid at room temperature, such as ice cream,
custards, puddings, and some refined cereals. A bland diet consists of foods that are soft, not very spicy,
and low in fiber. A soft diet or low residue includes foods that are low fiber and easily digested, such as
pastas, casseroles, canned fruits, and vegetables. A regular diet has no restrictions. (Potter, Perry, 7 ed.,
pp. 981-984.)
, A client returns from surgery. Which data obtained during assessment would indicate the client is
experiencing severe pain?
a) Decreased heart rate, decreased blood pressure, decreased respirations
b) Increased heart rate, decreased blood pressure, decreased respirations
c) Increased heart rate, increased blood pressure, increased respirations
d) Decreased heart rate, decreased blood pressure, increased respirations ANS: c) Increased heart rate,
increased blood pressure, increased respirations
When a client is experiencing severe pain, all body functions are increased, as the sympathetic response
in this instance is stimulated: increased heart rate, blood pressure, and respiratory rate. (Lewis, et al, 8
ed., pp. 374-375.)
The nurse is caring for a client with postoperative repair of an aortic aneurysm. What is a nursing
concern regarding a postoperative internal hemorrhage?
a) Hypervolemia may occur when the sequestered blood returns to the vascular system.
b) Signs of shock are more severe because the bleeding is arterial.
c) Initial symptoms may be masked by the size of abdominal cavity and surgical pain.
d) Signs of shock do not appear until permanent damage has occurred. ANS: c) Initial symptoms may be
masked by the size of abdominal cavity and surgical pain.
Because the bleeding is internal, it is harder to detect, and consequently, the client can lose a lot of
blood before the condition is identified. The accumulation of blood within a confined area can put
pressure on vital organs. For example, 750 mL will occupy enough space in a limb to cause swelling and
pain. With bleeding into the peritoneal cavity; however, the blood will usually spread throughout the
cavity, causing little, if any, initial discomfort. (Lewis, et al, 8 ed., pp. 367-372, 869-870.)
The nurse is preparing a client for surgery. Which of the following items on the client's presurgery lab
results would indicate a need to contact the surgeon?
a) Platelet count of 325,000 mm3
b) Total cholesterol of 325 mg/dL
c) Blood urea nitrogen (BUN) 17 mg/dL
d) Hemoglobin 9.5 g/dL ANS: d) Hemoglobin 9.5 g/dL
The hemoglobin level is low, and the nurse needs to make sure the surgeon has the most recent
laboratory values before surgery. This client may need a transfusion before surgery. The cholesterol is
elevated but is not a concern before surgery. The platelets and the BUN are within normal limits.
(Potter, Perry, 7 ed., pp. 1376-1377.)
In the recovery room, the postoperative client suddenly becomes restless with circumoral cyanosis.
What is the first nursing action?
a) Begin administration of oxygen through a nasal cannula.
b) Call for assistance.
c) Reposition the head and determine patency of airway.
d) Insert an oral airway and suction the nasopharynx. ANS: c) Reposition the head and determine
patency of airway.
It is important to determine whether the airway is patent and whether the client is breathing. If a
significant amount of mucus and gurgling are noted in the upper airway, the client should be suctioned.
Insertion of an oral airway may be necessary to maintain an open airway, but the airway must be
assessed before determining a course of action. Inserting an airway will not solve the problem if the
client is not breathing. (Lewis, Dirksen, Heitkemper et al, 8 ed., pp. 366-368.)
,The nurse is preparing the preoperative client for surgery. Which of the following statements indicate to
the nurse that the client is knowledgeable about his impending surgery? Select all that apply.
a) "After surgery, I will need to wear the pneumatic compression device while sitting in the chair."
b) "The skin prep area is going to be longer and wider than the anticipated incision."
c) "I cannot have anything to drink or eat after midnight on the night before the surgery."
d) "To ensure my safety, a time-out for identification will be conducted in the operating room before
surgery."
e) "I will be given the consent form, and I will sign it after I get to the operating room." ANS: b, c, d
Having the skin prep area being longer and wider than the actual incision, maintaining NPO status after
midnight, and performing the time-out identification indicate a correct understanding of the
preoperative teaching. The pneumatic compression device is worn during bed rest and is removed when
the client is out of bed or ambulating. The informed consent document should be signed before
preoperative medication administration and before the client enters the operating room. Part of safety
standards is to initiate a time-out in the operating room before the surgery is started. (Lewis, Dirksen,
Heitkemper, et al, 8 ed., pp. 341-343.)
A client is scheduled for major surgery. What is most important for the nurse to do before surgery?
a) Remove all jewelry or tape wedding rings.
b) Verify that all laboratory work is complete.
c) Inform family or next of kin of recovery procedure.
d) Check that consent forms are signed. ANS: d) Check that consent forms are signed.
Consent forms must be signed by the client, family, or guardian with medical power of attorney before
any procedure can be done. Consent forms also must be signed before the client receives any narcotics
or medications that would affect his reasoning. These medications are frequently in the preoperative
medications ordered. (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 344-346.)
,The nurse is caring for a first-day postoperative surgical client. Prioritize the client's desired dietary
progression by numbering the following from 1 to 4 (with 1 being the first step and 4 being the last
step).
_Full liquid
_NPO
_Clear liquid
_Soft ANS: 1) NPO
2) Clear liquid
3) Full liquid
4) Soft
The client's status is NPO immediately after surgery. Desired diet progression advances next to clear
liquid. Desired diet progression then advances to full liquid. Desired diet progression next advances to a
soft diet and then finally to a regular diet as tolerated by the client. (Potter, Perry, 7 ed., pp. 1404-1405.)
A postoperative patient receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the
foods on the client's tray, what would the nurse anticipate the client's current diet order to be?
a) Bland diet
b) Soft diet
c) Full liquid diet
d) Regular diet ANS: c) Full liquid diet
A full liquid diet includes liquids, as well as foods that are liquid at room temperature, such as ice cream,
custards, puddings, and some refined cereals. A bland diet consists of foods that are soft, not very spicy,
and low in fiber. A soft diet or low residue includes foods that are low fiber and easily digested, such as
pastas, casseroles, canned fruits, and vegetables. A regular diet has no restrictions. (Potter, Perry, 7 ed.,
pp. 981-984.)
, A client returns from surgery. Which data obtained during assessment would indicate the client is
experiencing severe pain?
a) Decreased heart rate, decreased blood pressure, decreased respirations
b) Increased heart rate, decreased blood pressure, decreased respirations
c) Increased heart rate, increased blood pressure, increased respirations
d) Decreased heart rate, decreased blood pressure, increased respirations ANS: c) Increased heart rate,
increased blood pressure, increased respirations
When a client is experiencing severe pain, all body functions are increased, as the sympathetic response
in this instance is stimulated: increased heart rate, blood pressure, and respiratory rate. (Lewis, et al, 8
ed., pp. 374-375.)
The nurse is caring for a client with postoperative repair of an aortic aneurysm. What is a nursing
concern regarding a postoperative internal hemorrhage?
a) Hypervolemia may occur when the sequestered blood returns to the vascular system.
b) Signs of shock are more severe because the bleeding is arterial.
c) Initial symptoms may be masked by the size of abdominal cavity and surgical pain.
d) Signs of shock do not appear until permanent damage has occurred. ANS: c) Initial symptoms may be
masked by the size of abdominal cavity and surgical pain.
Because the bleeding is internal, it is harder to detect, and consequently, the client can lose a lot of
blood before the condition is identified. The accumulation of blood within a confined area can put
pressure on vital organs. For example, 750 mL will occupy enough space in a limb to cause swelling and
pain. With bleeding into the peritoneal cavity; however, the blood will usually spread throughout the
cavity, causing little, if any, initial discomfort. (Lewis, et al, 8 ed., pp. 367-372, 869-870.)
