ATI LPN
Perioperative Nursing Care NCLEX Questions Questions
Question 1 of 5
A nurse is caring for a 6-year-old patient with cystic fibrosis. In order to enhance the childs nutritional status, what intervention should most likely be included in the plan of care?
Correct Answer: A
Rationale: In cystic fibrosis (CF), pancreatic enzyme supplementation with meals is essential to enhance nutritional status, as 90% of patients have exocrine pancreatic insufficiency from CFTR mutations. Thick mucus blocks pancreatic ducts, preventing digestive enzymes (e.g., lipase, protease) from reaching the gut, causing malabsorption of fats and proteins supplements (e.g., pancrelipase) correct this, improving calorie uptake critical for growth in a 6-year-old. Small, frequent meals aid digestion but don't address enzyme deficiency alone. TPN, intravenous nutrition, is reserved for severe cases, not routine CF care. Magnesium, thiamine, and iron aren't typically deficient in CF; fat-soluble vitamins (A, D, E, K) are supplemented instead due to fat malabsorption. The nurse's inclusion of enzyme therapy dosed with meals and snacks optimizes nutrition, countering CF's gastrointestinal impact, vital for this child's development.
Question 2 of 5
A nurse is admitting a new patient who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the patient achieve the goal of maintaining effective oxygenation?
Correct Answer: A
Rationale: In a COPD exacerbation, teaching diaphragmatic breathing best helps maintain effective oxygenation by retraining the patient's inefficient, shallow pattern. This technique abdomen expands on inhale, contracts on exhale lowers respiratory rate, boosts alveolar ventilation, and reduces air trapping from hyperinflation, improving O2 uptake. Supplementary oxygen via face mask corrects hypoxemia but doesn't address breathing mechanics, risking CO2 retention if unmonitored. Airway suctioning clears secretions, irrelevant in COPD unless pneumonia complicates it. Exercise programs aid long-term fitness but are impractical acutely due to dyspnea. The nurse's instruction hands-on, practiced optimizes oxygenation naturally, per COPD rehabilitation, empowering the patient during and post-exacerbation.
Question 3 of 5
The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse's best next step?
Correct Answer: A
Rationale: If a patient can't perform leg exercises correctly despite clear teaching, the nurse should assess for anxiety, pain, or fatigue barriers to learning. Anxiety about surgery may distract, pain may limit movement, and fatigue may sap energy, all common preoperatively. Asking 'why' risks defensiveness and assumes unwillingness, not inability. Delaying practice misses the urgency of preoperative preparation. Reassessing teaching methods is secondary; the issue likely isn't the method but the patient's state. This assessment identifies reversible obstacles, enabling tailored support like pain relief or relaxation techniques to ensure mastery, critical for preventing postoperative clots per safety standards.
Question 4 of 5
The nurse has administered an anxiolytic as a preoperative medication to the patient going to surgery. Which of the following is the best next step?
Correct Answer: C
Rationale: After an anxiolytic, instructing the patient to call for help to use the restroom prevents falls from sedation-induced drowsiness or unsteadiness, a key safety step. Consent should precede medication, as sedation impairs judgment asking now is invalid. Wasting unused meds follows policy but isn't urgent. Notifying the operating suite may occur, but patient safety trumps communication timing. The nurse's instruction raising side rails, placing call light near ensures immediate protection, aligning with preoperative care to mitigate risks from altered consciousness.
Question 5 of 5
The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action?
Correct Answer: B
Rationale: Obtaining vital signs post-transport compares them to PACU baselines, monitoring for variations (e.g., hypotension from movement) to ensure stability. It's not just the first assessment step context matters. It's not merely to confirm nurse attention or follow policy, though policies may align. This rationale tracks physiological response, critical for early complication detection (e.g., bleeding), aligning with safe handoff practices between units.