NSG 6435 Exam queries and answers
graded A+
A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report - ANS✅✅ANS: D
Hand-offs are a critical time in client care, and poor communication during this time can lead to
serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the
priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the
client is warm is a lower priority.
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients.
Which client should the nurse assess first?
a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respiratory rate of 6 breaths/min
d. Client with a temperature of 96° F (35.6° C) - ANS✅✅ANS: C
The respiratory rate is the most critical vital sign for any client who has undergone general
anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low
and indicates respiratory depression. The nurse should assess this client first. A blood pressure of
100/50 mm Hg is slightly low and may be within that client's baseline. A pulse of 118 beats/min is
slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96° F
is slightly low and the client needs to be warmed. But none of these other vital signs take priority
over the respiratory rate.
A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%.
What action by the nurse is most appropriate?
a. Assess other indicators of oxygenation.
b. Call the Rapid Response Team.
c. Notify the anesthesia provider.
d. Prepare to intubate the client. - ANS✅✅ANS: A
If a postoperative client's oxygen saturation (SaO2) drops below 95% (or the client's baseline), the
nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call
,the Rapid Response Team. Since this is approximately a 3% drop, the nurse should further assess the
client. Intubation (if the client is not intubated already) is not warranted.
Ten hours after surgery, a postoperative client reports that the antiembolism stockings and
sequential compression devices itch and are too hot. The client asks the nurse to remove them.
What response by the nurse is best?
a. "Let me call the surgeon to see if you really need them."
b. "No, you have to use those for 24 hours after surgery."
c. "OK, we can remove them since you are stable now."
d. "To prevent blood clots you need them a few more hours." - ANS✅✅ANS: D
According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent
thromboembolic events during surgery are continued for 24 hours afterward. The nurse should
explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has
to wear the hose and compression devices does not educate the client. The nurse should not
remove the devices.
A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the client's
bed. The client's blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the
nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Lower the head of the bed.
d. Nothing; this is expected. - ANS✅✅ANS: C
A client who had epidural or spinal anesthesia may become hypotensive when the head of the bed is
raised. If this occurs, the nurse should lower the head of the bed to its original position. The Rapid
Response Team is not needed, nor is an increase in IV rate.
A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is
most important?
a. Allow the client to rest.
b. Auscultate lung sounds.
c. Document the episode.
d. Encourage the client to eat dry toast. - ANS✅✅ANS: B
Vomiting after surgery has several complications, including aspiration. The nurse should listen to the
client's lung sounds. The client should be allowed to rest after an assessment. Documenting is
, important, but the nurse needs to be able to document fully, including an assessment. The client
should not eat until nausea has subsided.
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What
assessment by the PACU nurse takes priority?
a. Airway
b. Bleeding
c. Breathing
d. Cardiac rhythm - ANS✅✅ANS: A
Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of
the circulation assessment, as is cardiac rhythm.
A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation.
Which IV-push medication and dose does the nurse prepare to administer?
a. Flumazenil (Romazicon) 0.2 to 1 mg
b. Flumazenil (Romazicon) 2 to 10 mg
c. Naloxone (Narcan) 0.4 to 2 mg
d. Naloxone (Narcan) 4 to 20 mg - ANS✅✅ANS: A
Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in this situation. The
correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.
A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does
not want medication. What action by the nurse is best to promote comfort?
a. Assess the client's pain on a 0-to-10 scale.
b. Assist the client into a position of comfort.
c. Have the client sit up in a recliner.
d. Tell the client when pain medication is due. - ANS✅✅ANS: B
Several nonpharmacologic comfort measures can help postoperative clients with their pain,
including distraction, music, massage, guided imagery, and positioning. The nurse should help this
client into a position of comfort considering the surgical procedure and position of any tubes or
drains. Assessing the client's pain is important but does not improve comfort. The client may be
more uncomfortable in a recliner. Letting the client know when pain medication can be given next is
important but does not improve comfort.
graded A+
A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report - ANS✅✅ANS: D
Hand-offs are a critical time in client care, and poor communication during this time can lead to
serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the
priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the
client is warm is a lower priority.
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients.
Which client should the nurse assess first?
a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respiratory rate of 6 breaths/min
d. Client with a temperature of 96° F (35.6° C) - ANS✅✅ANS: C
The respiratory rate is the most critical vital sign for any client who has undergone general
anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low
and indicates respiratory depression. The nurse should assess this client first. A blood pressure of
100/50 mm Hg is slightly low and may be within that client's baseline. A pulse of 118 beats/min is
slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96° F
is slightly low and the client needs to be warmed. But none of these other vital signs take priority
over the respiratory rate.
A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%.
What action by the nurse is most appropriate?
a. Assess other indicators of oxygenation.
b. Call the Rapid Response Team.
c. Notify the anesthesia provider.
d. Prepare to intubate the client. - ANS✅✅ANS: A
If a postoperative client's oxygen saturation (SaO2) drops below 95% (or the client's baseline), the
nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call
,the Rapid Response Team. Since this is approximately a 3% drop, the nurse should further assess the
client. Intubation (if the client is not intubated already) is not warranted.
Ten hours after surgery, a postoperative client reports that the antiembolism stockings and
sequential compression devices itch and are too hot. The client asks the nurse to remove them.
What response by the nurse is best?
a. "Let me call the surgeon to see if you really need them."
b. "No, you have to use those for 24 hours after surgery."
c. "OK, we can remove them since you are stable now."
d. "To prevent blood clots you need them a few more hours." - ANS✅✅ANS: D
According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent
thromboembolic events during surgery are continued for 24 hours afterward. The nurse should
explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has
to wear the hose and compression devices does not educate the client. The nurse should not
remove the devices.
A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the client's
bed. The client's blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the
nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Lower the head of the bed.
d. Nothing; this is expected. - ANS✅✅ANS: C
A client who had epidural or spinal anesthesia may become hypotensive when the head of the bed is
raised. If this occurs, the nurse should lower the head of the bed to its original position. The Rapid
Response Team is not needed, nor is an increase in IV rate.
A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is
most important?
a. Allow the client to rest.
b. Auscultate lung sounds.
c. Document the episode.
d. Encourage the client to eat dry toast. - ANS✅✅ANS: B
Vomiting after surgery has several complications, including aspiration. The nurse should listen to the
client's lung sounds. The client should be allowed to rest after an assessment. Documenting is
, important, but the nurse needs to be able to document fully, including an assessment. The client
should not eat until nausea has subsided.
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What
assessment by the PACU nurse takes priority?
a. Airway
b. Bleeding
c. Breathing
d. Cardiac rhythm - ANS✅✅ANS: A
Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of
the circulation assessment, as is cardiac rhythm.
A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation.
Which IV-push medication and dose does the nurse prepare to administer?
a. Flumazenil (Romazicon) 0.2 to 1 mg
b. Flumazenil (Romazicon) 2 to 10 mg
c. Naloxone (Narcan) 0.4 to 2 mg
d. Naloxone (Narcan) 4 to 20 mg - ANS✅✅ANS: A
Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in this situation. The
correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.
A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does
not want medication. What action by the nurse is best to promote comfort?
a. Assess the client's pain on a 0-to-10 scale.
b. Assist the client into a position of comfort.
c. Have the client sit up in a recliner.
d. Tell the client when pain medication is due. - ANS✅✅ANS: B
Several nonpharmacologic comfort measures can help postoperative clients with their pain,
including distraction, music, massage, guided imagery, and positioning. The nurse should help this
client into a position of comfort considering the surgical procedure and position of any tubes or
drains. Assessing the client's pain is important but does not improve comfort. The client may be
more uncomfortable in a recliner. Letting the client know when pain medication can be given next is
important but does not improve comfort.
