NCLEX Perioperative Nursing Questions

Question 1 of 5

The postoperative client complains of hearing a 'popping sound' and feeling 'something opening' when ambulating in the room. Which intervention should the nurse implement first?

A. Notify the surgeon the client has had an evisceration.B. Contact the surgery department to prepare for emergency surgery.C. Assess the operative site and cover the site with a moistened dressing.D. Explain this is a common feeling and tell the client to continue with activity.

Correct Answer: C

Rationale: A popping sound and opening sensation suggest dehiscence or evisceration; assessing and covering with a moist dressing stabilizes the site, the first step. Notification and surgery prep follow, and dismissing the symptom is unsafe.

Question 2 of 5

Which statement would be an expected outcome for the postoperative client who had general anesthesia?

A. The client will be able to sit in the chair for 30 minutes.B. The client will have a pulse oximetry reading of 97% on room air.C. The client will have a urine output of 30 mL per hour.D. The client will be able to distinguish sharp from dull sensations.

Correct Answer: B

Rationale: A pulse oximetry of 97% on room air indicates adequate oxygenation post-general anesthesia, a key outcome. Sitting, urine output, and sensation are secondary or unrelated.

Question 3 of 5

The circulating nurse notes a discrepancy in the needle count. What intervention should the nurse implement first?

A. Inform the other members of the surgical team about the problem.B. Assume the original count was wrong and change the record.C. Call the radiology department to perform a portable x-ray.D. Complete an occurrence report and notify the risk manager.

Correct Answer: A

Rationale: Informing the team prompts a recount and investigation, the first step to prevent retained needles. Assuming errors, ordering x-rays, or reporting are premature.

Question 4 of 5

Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?

A. Change the dressing over the surgical site.B. Teach the client how to perform incentive spirometry.C. Empty and record the amount of drainage in the JP drain.D. Auscultate the bowel sounds in all four (4) quadrants.

Correct Answer: C

Rationale: Emptying and recording JP drain output is a technical task within UAP scope. Dressing changes, teaching, and auscultation require nursing judgment.

Question 5 of 5

The client diagnosed with appendicitis has undergone an appendectomy. At two (2) hours postoperative, the nurse takes the vital signs and notes T 102.6°F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority.

Order the Items

Source Container

Increase the IV rate.

Notify the health-care provider.

Elevate the foot of the bed.

Check the abdominal dressing.

Determine if the IV antibiotics have been administered.

Correct Answer: C,A,B,D,E

Rationale: 1) Elevate foot of bed (Trendelenburg for hypotension); 2) Notify HCP (fever, tachycardia, hypotension suggest sepsis); 3) Increase IV rate (bolus for hypovolemia); 4) Check dressing (assess bleeding); 5) Confirm antibiotics (treat infection).

NCLEX Perioperative Nursing Questions | Nurselytic

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