ATI LPN
Perioperative Nursing Care NCLEX Questions Questions
Question 1 of 5
A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication?
Correct Answer: B
Rationale: Choice B as furosemide reduces elevated PAWP (preload) in cardiogenic shock, improving output. Albumin (choice A) increases preload, epinephrine (choice C) stresses the heart, and hydrocortisone (choice D) targets other shocks. This aligns with NCLEX Physiological Integrity, anticipating diuretics to manage fluid overload in heart failure.
Question 2 of 5
The nurse is caring for a patient who has just been brought to the postoperative unit following major surgery and notes that the patient has many tubes and monitors in place. Which will the nurse assess first?
Correct Answer: D
Rationale: The patient's endotracheal tube,' as airway maintenance is the highest priority post-surgery. The endotracheal tube ensures breathing, especially after major surgery where anesthesia may suppress respiration assessing its patency and position prevents hypoxia. 'Intravenous lines' (A) deliver fluids but aren't immediately life-threatening if delayed. 'Urinary catheter' (B) monitors output, a lower priority than airway. 'Nasogastric tube' (C) manages gastric contents, secondary to breathing. In nursing, the ABCs (airway, breathing, circulation) guide care; a blocked or dislodged tube could be fatal, unlike other options. This aligns with NCLEX Management of Care priorities, emphasizing clinical judgment in emergencies where airway trumps all.
Question 3 of 5
The nurse is caring for a patient who is recovering from chest surgery. Which action by the patient indicates that additional teaching is needed about how to use the ordered incentive spirometer correctly?
Correct Answer: A
Rationale: The patient breathes into the spirometer so that the marker rises slowly,' as it's incorrect patients inhale through the spirometer to raise the marker, not exhale. This indicates a need for reteaching proper technique to expand lungs. '5 to 12 times hourly' (B), 'tight seal' (C), and 'hold breath 3-5 seconds' (D) are correct steps. In nursing, spirometry education prevents atelectasis; misusing it (exhaling) negates benefits. A aligns with NCLEX Reduction of Risk Potential and Patient Education, pinpointing the error needing correction.
Question 4 of 5
The nurse educator facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse educator to intervene?
Correct Answer: C
Rationale: The student wears surgical scrubs in the semirestricted area,' as it's incorrect and requires intervention. In the semirestricted area (e.g., corridors), staff must wear surgical attire *and* cover all head and facial hair to maintain asepsis scrubs alone are insufficient. 'Mask at the sink area' (A) is correct for the restricted zone. 'Street clothes in the unrestricted area' (B) is appropriate (e.g., nursing station). 'Covering head and hair in the semirestricted area' (D) meets requirements when paired with scrubs. In nursing, enforcing surgical suite zones prevents contamination; C's omission of hair covering violates protocol, risking microbial spread. This aligns with NCLEX Safe and Effective Care Environment, emphasizing strict adherence to aseptic standards over partial compliance.
Question 5 of 5
A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report?
Correct Answer: C
Rationale: Weak chest wall movement,' as neuromuscular blockers can cause respiratory muscle weakness, risking hypoxemia a critical finding to report in PACU. 'Laryngospasm' (A) isn't typical with these agents. 'Nausea' (B) and 'confusion' (D) are less urgent (options missing in OCR). In nursing, respiratory depression is a top concern; C aligns with NCLEX Physiological Integrity, prioritizing airway and breathing assessment. (Note: OCR omits A, B, D assumed from context.)