ATI LPN
Perioperative Nursing Care NCLEX Questions Questions
Question 1 of 5
The nurse transfers a patient to the PACU with an incision and drainage of an abscess in the right groin under general anesthesia. Blood pressure is 80/47 mm Hg, heart rate 117/min in sinus tachycardia, respiratory rate 28/min, pulse oximetry reading 93% on oxygen at 3 L nasal cannula, temp is 38.5°C. Using the SBAR charting format, which information should be included in assessment?
Correct Answer: C
Rationale: In SBAR's assessment, vital signs and wound output are key, showing instability (hypotension, tachycardia, fever). Procedure is situation; orders are recommendation; history is background. The rationale follows SBAR: assessment presents objective data (BP 80/47, HR 117, temp 38.5°C), signaling shock or infection, guiding interventions. Nursing communicates clearly, ensuring team response, distinct from context or orders.
Question 2 of 5
The nurse in an ambulatory surgery center has administered the following preoperative medications to a patient scheduled for general surgery: diazepam (Valium), cefazolin (Ancef), and famotidine (Pepcid). What mode of transportation to the operating room (OR) would be the most appropriate for the nurse to arrange for this patient?
Correct Answer: A
Rationale: Stretcher with side rails up and accompanied by OR transport personnel,' as diazepam's sedative effects increase fall risk, requiring a stretcher unlike 'ambulatory with escort' (B, D) or 'wheelchair with family' (C), less safe. In nursing, patient safety post-sedation is paramount; A aligns with NCLEX Perioperative, prioritizing secure transport based on medication effects.
Question 3 of 5
Which of the following items is included in a valid informed consent? Select all that apply
Correct Answer: C
Rationale: Valid informed consent requires it be freely given , a physician obtains it , and age isn't strictly 16 or 18 capacity matters more. Choice C is primary for CSV. The rationale defines consent: it must be voluntary (no coercion), physician-led (surgeon typically), and based on competence, not arbitrary age (minors with guardians consent). Physician assistants (choice E, not D here) don't typically obtain it. Nursing ensures this process witnessing, checking voluntariness upholding patient autonomy, distinct from age-based or assistant-led misconceptions.
Question 4 of 5
A client is experiencing confusion in the immediate postoperative period. Which of the following assessments is essential to determine the reason for the confusion?
Correct Answer: C
Rationale: Airway status,' as hypoxia is a common cause of postop confusion, and ABCs prioritize airway unlike 'consciousness' (A), an outcome, 'cardiac rhythm' (B), secondary, or 'anxiety' (D), less urgent. In nursing, oxygenation drives assessment; C aligns with NCLEX Perioperative, ensuring respiratory stability first.
Question 5 of 5
The most common source of pathogens in the surgical suite is:
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.