NCLEX Questions: Perioperative Care

NCLEX Questions: Perioperative Care

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The nurse measures the client's blood pressure, pulse, and capillary refill prior to sending the client to the operating room. Which concept related to perioperative care is the nurse implementing?

• Quality control
• Perfusion
• Infection control

D. Safety ✔✔Answer: B

Rationale: The concept of perfusion is related to perioperative care. Nurses must be aware of the client's hemodynamic status and understand the guidelines for perfusion. The client's hemodynamic status is measured through blood pressure, pulse, and capillary refill. Measuring blood pressure, pulse, and capillary refill does not directly support the concepts of safety, quality control, or infection control.

The nurse is discussing the challenges when caring for a pediatric surgical client. Which is the biggest challenge that must be included?

• Reducing the risk of pneumonia
• Preventing skin tears
• Preventing hypothermia

D. Reducing the risk of venous thromboembolism ✔✔Answer: C

Rationale: For the pediatric client, temperature regulation may be the biggest challenge. Preventing skin tears due to fragile skin, reducing the risk of pneumonia, and reducing the risk of venous thromboembolism due to inactivity are concerns for nursing care of the older client having a surgical procedure.

A preoperative client asks if blood products will be used during the procedure. Which laboratory value should the nurse explain is used to determine the client's need for blood products? (Select all that apply.)

• Platelets

• Hematocrit
• Hemoglobin
• Prothrombin time

E. Red blood cell count ✔✔Answer: A, B, C, E

Rationale: The diagnostic tests of platelets, hematocrit, hemoglobin, and red blood cell count are used to determine if a blood transfusion is needed during the surgical procedure. Prothrombin time is used to determine the client's risk for bleeding.

While preparing medications for a client scheduled for surgery, the nurse observes that medications are scheduled for 0800 hours, analyzes the medication vial, and reviews the client's armband. Which right of medication administration is the nurse performing? (Select all that apply.)

• Right time
• Right client
• Right teaching
• Right medication

E. Right assessment ✔✔Answer: A, B, D

Rationale: The rights of medication administration include right time, right client, and right medication. Right teaching and right assessment are not considered a part of the basic rights of medication administration.

A 78-year-old client is scheduled for surgery. Which intervention should the nurse make a priority when planning this client's care? (Select all that apply.) A.Preventing infection

• Promoting skin integrity
• Ensuring adequate oral intake
• Maximizing respiratory function

E. Maintaining a normal body temperature ✔✔Answer: A, B, D, E

Rationale: Lifespan considerations for an older client having surgery include maintaining skin integrity, preventing surgical infections, preventing the development of pneumonia, and maintaining a normal body temperature. Oral intake is not a specific lifespan consideration for an older client having surgery.

The nurse assessed an 80-year-old client who is scheduled for surgery and becomes concerned that the client is at risk for a postoperative complication. Which assessment finding caused the nurse's concern?

• Practices deep breathing and coughing
• Bowel sounds audible in all four quadrants
• Wears an anti-embolism stockings

D. Skin friable over bony prominences ✔✔Answer: D

Rationale: Friable skin increases the older client's risk for developing pressure ulcers, which could be exacerbated during the surgical case. This is the information that the nurse should communicate to the intraoperative nurse. Wearing antiembolism stockings prevents the development of venous thromboembolism. Audible bowel sounds indicate an intact gastrointestinal system. Practicing deep breathing and coughing helps prevent the development of postoperative respiratory complications.

During the preoperative assessment the client tells the nurse, "I had a cup of black coffee this morning." Which intervention should be the nurse's priority?

• Administer the preoperative medication.
• Instruct the client to refrain from further intake.
• Notify the surgeon.

D. Document the fluid intake in the medical record. ✔✔Answer: C

Rationale: The nurse should notify the surgeon with the information if the client has had anything to eat or drink within 8 hours prior to surgery because this increases the client's risk of aspiration.The surgical procedure will be cancelled, especially if the surgery is elective. The client should not be given the preoperative medication until the surgeon is notified of the fluid intake. The nurse needs to do more than document the information in the medical record. The client should have been instructed to refrain from food or fluids for 8 hours before the surgery prior to arriving to the hospital for the procedure.

The nurse is preparing a client for a surgical procedure. Which priority action should the nurse include to reduce the client's risk of developing a postoperative complication? (Select all that apply.)

• Monitoring body temperature
• Observing for muscle twitching
• Monitoring urine concentration
• Monitoring blood pressure and heart rate
• Ensuring that aseptic technique is used for the procedure ✔✔Answer: A, D, E

Rationale: Open procedures place the client at a higher risk for blood loss, hypothermia and surgical site infections (SSIs). The nurse should monitor body temperature, blood pressure, and heart rate and ensure that aseptic technique is used for the procedure. Urine concentration is used to monitor for hypernatremia and hypovolemia. Muscle twitching is associated with hyponatremia.

The nurse is assessing a client preoperatively. Which finding should alert the nurse that the client is at risk for developing a surgical infection? (Select all that apply.)

• Body mass index of 33.7
• Fasting blood glucose level of 258 mg/dL
• Prescribed steroids for chronic lung disease
• Takes acetaminophen daily for arthritis pain

E. Treated for gastric ulcers caused by H. pylori ✔✔Answer: A, B, C

Rationale: Clients with an increased body mass index (BMI), who have diabetes, or who take immunosuppressants are at a higher risk for acquiring a postoperative infection. Taking acetaminophen and having a history of H. pylori does not increase the risk for developing a postoperative infection.

Which information should the nurse include in the preoperative preprocedure verification process during the preoperative phase? (Select all that apply.)

• Correct surgical procedure
• Location of drains
• Development of complications
• Antibiotic administered