Questions and Answers Solved

NCLEX PN - Perioperative Care Questions and Answers Solved Correctly

the nurse is developing a plan of care for a client who is scheduled for surgery.the nurse should include which activity in the nursing care plan for the client on the day of surgery?

• have the client void immediately before surgery

• avoid oral hygiene and rinsing with moutwash

• verify that the client has not eaten for the last 24 hours

• report immediately any slight increase in blood pressure or pulse ✔✔A) have the client void

immediately before surgery

rationale the nurse should assist the client with voiding 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 8 hours before surgery rather than 24 hours.a slight increase in blood pressure and pulse is common during the peroperative period; this is generally the result of anxiety.

the nurse is caring for a client who is scheduled for surgery.the client is concerned about the surgical procedure. which action should alleviate the client's fears and misconceptions about surgery?

• tell the client that preoperative fear is normal

• explain all nursing care and possible discomfort that may result

• ask the client to discuss information known about the planned surgery

• provide explanations about the procedures involved in the planned surgery ✔✔C) ask the client

to discuss information known about the planned surgery

rationale explanations should begin with the information that the client knows.option A is a block to communication and options B and D may produce additional anxiety in the client.

the nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center.the nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin).the nurse reports the information to the health care provider and anticipates that the provider will prescribe which?

• discontinue the aspirin immediately

• continue to take the aspirin as prescribed

• discontinue the aspirin 48 hours before the scheduled surgery

• decrease the dose of the aspirin to half of what is normally taken ✔✔C) discontinue the aspirin

48 hours before the scheduled surgery

rational e anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery.

aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery.however, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled.therefore, the remaining options are incorrect.

the nurse obtains the vital signs on a postoperative client who just returned to the nursing unit.the client's blood pressure (BP) is 100/60 mmHg, the pulse is 90 beats per minute.on the basis of these findings, which nursing action should be performed?

• shake the client gently to arouse

• continue to monitor the vital signs

• call the RN immediatel y

• cover the client with a warm blanket ✔✔B) continue to monitor the vital signs

rationale a slightly lower-than-normal BP and an increased pulse rate are common after surgery.the level of consciousness can be determined by checking the client's response to light touch and verbal stimuli rather than by shaking the client.warm blankets are applied to maintain the client's body temperature.there is no reason to contact the RN immediately.

a client arrives to the surgical nursing unit after surgery.what should be the initial nursing action after surgery?

• patency of the airway

• dressing for bleeding

• tubes or drains for patency

• vital signs to compare with preoperative measures ✔✔A) patency of the airway

rationale if the airway is not patent, immediate measures must be taken for the survival of the client.after checking the client's airway, the nurse would then check the client's vital signs, and this would be followed by checking the dressings, tubes and drains

the nurse is monitoring an adult client for postoperative complications.which is most indicative of a potential postoperative complication that requires further observation?

• a urinary output of 20 ml/hr

• a temperature of 37.6 C (99.6 F)

• a blood pressure of 100/70 mmHg

• serous drainage on the surgical dressing ✔✔A) urinary output of 20 ml/hr

rationale urine output is maintained at a minimum of at least 30 ml/hr for an adult.an output of less than 30 ml/hr for each of 2 consecutive hours should be reported to the surgeon.a temperature more than 37 C (100 F) or less than 36.1 C (97 F) and a falling systolic blood pressure less than 90 mmHg are to be reported.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