A client who has had abdominal surgery complains of feeling as though 'something gave way' in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? [Note: Single-answer format assumed from prior pattern despite 'select all']

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NCLEX Questions Perioperative Care Questions

Question 1 of 5

A client who has had abdominal surgery complains of feeling as though 'something gave way' in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? [Note: Single-answer format assumed from prior pattern despite 'select all']

Correct Answer: D

Rationale: Apply a sterile dressing soaked with normal saline,' as initial care for evisceration protects protruding organs though all options (A-D) are valid in sequence, single-answer format prioritizes first action. In nursing, sterile coverage prevents infection; D aligns with NCLEX Perioperative, addressing urgent wound care. (Note: OCR lists multiple, but prior format suggests single.)

Question 2 of 5

The nurse is preparing the patient for surgery. Which common laboratory tests does the nurse anticipate to be ordered? (Select all that apply.)

Correct Answer: C

Rationale: Common preoperative lab tests include urinalysis , electrolyte levels , clotting studies (choice E, not listed), and serum creatinine (choice F, not listed). Total cholesterol and uric acid assess chronic conditions, not surgical readiness. The rationale focuses on perioperative needs: urinalysis detects infections or kidney issues; electrolytes ensure metabolic balance; clotting studies prevent bleeding risks; creatinine evaluates renal function for anesthesia clearance. These tests identify complications (e.g., infection, coagulopathy) critical for safety, aligning with nursing's role in preparing patients for anesthesia and surgery, unlike non-urgent lipid or uric acid checks.

Question 3 of 5

During surgery, what things do anesthesia personnel monitor, measure, and assess? (Select all that apply.)

Correct Answer: C

Rationale: Anesthesia personnel monitor cardiopulmonary function , level of anesthesia , vital signs (choice F, not listed), and intake/output . Room temperature and family concerns (choice E) aren't their focus. The rationale centers on physiological stability: tracking heart, lungs, anesthesia depth, and fluids ensures safe sedation and oxygenation. Nursing collaborates by observing these, but anesthesia's expertise drives real-time adjustments, critical for preventing overdose or hypoxia, distinct from environmental or emotional monitoring.

Question 4 of 5

Which medical condition increases a patient's risk for surgical wound infection?

Correct Answer: C

Rationale: Diabetes mellitus increases wound infection risk due to impaired immunity and healing. Anxiety , hiatal hernia , and amnesia don't directly affect wounds. The rationale explains pathophysiology: hyperglycemia in diabetes fosters bacterial growth and delays repair, elevating infection rates. Nursing monitors glucose and wound care, mitigating this common surgical risk, distinct from unrelated conditions.

Question 5 of 5

A patient who is 2 days postoperative for abdominal surgery states, 'I coughed and heard something pop.' The nurse's immediate assessment reveals an opened incision with a portion of large intestine protruding. Which statements apply to this clinical situation? (Select all that apply.)

Correct Answer: B

Rationale: This is an emergency with incision evisceration (choice E), requiring moist saline dressings . Dehiscence is partial; urgency understates severity. The rationale explains urgency: protruding intestines signal evisceration, a life-threatening event needing immediate surgery. Nursing covers with saline to prevent drying, calls for help, and stabilizes, distinguishing from dehiscence (outer split), prioritizing rapid intervention.

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