MS: PERIOPERATIVE CARE EXAM
QUESTIONS AND ANSWERS 100% PASS
1. Urinary output of 20 mL/hour
Rationale:
Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less
than 30 mL for 2 consecutive hours should be reported to the health care provider. A
temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling systolic blood
pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's
preoperative or baseline blood pressure is used to make informed postoperative comparisons.
Moderate or light serous drainage from the surgical site is considered normal. - ANS The
nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago
to the surgical unit. The nurse plans to monitor which parameter most carefully during the next
hour?
1. Urinary output of 20 mL/hour
2. Temperature of 37.6°C (99.6°F)
3. Blood pressure of 100/70 mm Hg
4. Serous drainage on the surgical dressing
1. "Use of an incentive spirometer will help prevent pneumonia."
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Rationale:
Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli.
Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung
crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer
helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of
oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect
hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid
imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are
often given intravenous fluids to prevent a deficit; however, this is not related to coughing and
deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery
that disrupts blood - ANS The nurse is teaching a client about coughing and deep-breathing
techniques to prevent postoperative complications. Which statement is most appropriate for
the nurse to make to the client at this time as it relates to these techniques?
1. "Use of an incentive spirometer will help prevent pneumonia."
2. "Close monitoring of your oxygen saturation will detect hypoxemia."
3. "Administration of intravenous fluids will prevent or treat fluid imbalance."
4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."
3. Have the client void immediately before going into surgery.
Rationale:
The nurse would assist the client to void immediately before surgery so that the bladder will be
empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually
has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery
instead of 24 hours. A slight increase in blood pressure and pulse is common during the
preoperative period and is usually the result of anxiety. - ANS The nurse is creating a plan of
care for a client scheduled for surgery. The nurse should include which activity in the nursing
care plan for the client on the day of surgery?
1. Avoid oral hygiene and rinsing with mouthwash.
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,2. Verify that the client has not eaten for the last 24 hours.
3. Have the client void immediately before going into surgery.
4. Report immediately any slight increase in blood pressure or pulse.
4. Obtain a 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 2 persons who hear the family member's oral consent. The 2 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 the data in the question do not indicate an emergency.
Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies regard - ANS A
client with a 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 most appropriate action in the care of this client?
1. Obtain a court order for the surgery.
2. Have the charge nurse sign the informed consent immediately.
3. Send the client to surgery without the consent form being signed.
4. Obtain a telephone consent from a family member, following agency policy.
3. "Can you share with me what you've been told about your surgery?"
Rationale:
Explanations should begin with the information that the client knows. By providing the client
with individualized explanations of care and procedures, the nurse can assist the client in
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, handling anxiety and fear for a smooth preoperative experience. Clients who are calm and
emotionally prepared for surgery withstand anesthesia better and experience fewer
postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the
entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety
and is focused on postoperative care. - ANS A preoperative client expresses anxiety to the
nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further
discussion between the client and the nurse?
1. "If it's any help, everyone is nervous before surgery."
2. "I will be happy to explain the entire surgical procedure to you."
3. "Can you share with me what you've been told about your surgery?"
4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can
anticipate."
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90
degrees.
Rationale:
For optimal lung expansion with the incentive spirometer, the client should assume the semi
Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly
while the client inhales slowly, with a constant flow through the unit. The breath should be held
for 5 seconds before exhaling slowly. - ANS The nurse is conducting preoperative teaching
with a client about the use of an incentive spirometer. The nurse should include which piece of
information in discussions with the client?
1. Inhale as rapidly as possible.
2. Keep a loose seal between the lips and the mouthpiece.
3. After maximum inspiration, hold the breath for 15 seconds and exhale.
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90
degrees.
4 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
QUESTIONS AND ANSWERS 100% PASS
1. Urinary output of 20 mL/hour
Rationale:
Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less
than 30 mL for 2 consecutive hours should be reported to the health care provider. A
temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling systolic blood
pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's
preoperative or baseline blood pressure is used to make informed postoperative comparisons.
Moderate or light serous drainage from the surgical site is considered normal. - ANS The
nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago
to the surgical unit. The nurse plans to monitor which parameter most carefully during the next
hour?
1. Urinary output of 20 mL/hour
2. Temperature of 37.6°C (99.6°F)
3. Blood pressure of 100/70 mm Hg
4. Serous drainage on the surgical dressing
1. "Use of an incentive spirometer will help prevent pneumonia."
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Rationale:
Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli.
Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung
crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer
helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of
oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect
hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid
imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are
often given intravenous fluids to prevent a deficit; however, this is not related to coughing and
deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery
that disrupts blood - ANS The nurse is teaching a client about coughing and deep-breathing
techniques to prevent postoperative complications. Which statement is most appropriate for
the nurse to make to the client at this time as it relates to these techniques?
1. "Use of an incentive spirometer will help prevent pneumonia."
2. "Close monitoring of your oxygen saturation will detect hypoxemia."
3. "Administration of intravenous fluids will prevent or treat fluid imbalance."
4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."
3. Have the client void immediately before going into surgery.
Rationale:
The nurse would assist the client to void immediately before surgery so that the bladder will be
empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually
has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery
instead of 24 hours. A slight increase in blood pressure and pulse is common during the
preoperative period and is usually the result of anxiety. - ANS The nurse is creating a plan of
care for a client scheduled for surgery. The nurse should include which activity in the nursing
care plan for the client on the day of surgery?
1. Avoid oral hygiene and rinsing with mouthwash.
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,2. Verify that the client has not eaten for the last 24 hours.
3. Have the client void immediately before going into surgery.
4. Report immediately any slight increase in blood pressure or pulse.
4. Obtain a 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 2 persons who hear the family member's oral consent. The 2 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 the data in the question do not indicate an emergency.
Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies regard - ANS A
client with a 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 most appropriate action in the care of this client?
1. Obtain a court order for the surgery.
2. Have the charge nurse sign the informed consent immediately.
3. Send the client to surgery without the consent form being signed.
4. Obtain a telephone consent from a family member, following agency policy.
3. "Can you share with me what you've been told about your surgery?"
Rationale:
Explanations should begin with the information that the client knows. By providing the client
with individualized explanations of care and procedures, the nurse can assist the client in
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, handling anxiety and fear for a smooth preoperative experience. Clients who are calm and
emotionally prepared for surgery withstand anesthesia better and experience fewer
postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the
entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety
and is focused on postoperative care. - ANS A preoperative client expresses anxiety to the
nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further
discussion between the client and the nurse?
1. "If it's any help, everyone is nervous before surgery."
2. "I will be happy to explain the entire surgical procedure to you."
3. "Can you share with me what you've been told about your surgery?"
4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can
anticipate."
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90
degrees.
Rationale:
For optimal lung expansion with the incentive spirometer, the client should assume the semi
Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly
while the client inhales slowly, with a constant flow through the unit. The breath should be held
for 5 seconds before exhaling slowly. - ANS The nurse is conducting preoperative teaching
with a client about the use of an incentive spirometer. The nurse should include which piece of
information in discussions with the client?
1. Inhale as rapidly as possible.
2. Keep a loose seal between the lips and the mouthpiece.
3. After maximum inspiration, hold the breath for 15 seconds and exhale.
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90
degrees.
4 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
