ATI LPN
NCLEX Questions Perioperative Care Questions
Question 1 of 5
The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patients risk of developing pulmonary emboli (PE)?
Correct Answer: A
Rationale: Pulmonary embolism (PE) risk post-surgery stems from venous stasis, a component of Virchow's triad, making early ambulation the most effective preventive measure. Walking within hours of surgery enhances venous return, prevents deep vein thrombosis (DVT) formation the primary PE source and counters immobility's prothrombotic effects. Increased protein intake aids wound healing but doesn't directly reduce clotting risk. Maintaining a supine position prolongs stasis, heightening DVT and PE likelihood, especially post-surgery when mobility is already limited. Combining aspirin with warfarin increases bleeding risk without superior PE prevention over warfarin alone, and anticoagulants are secondary to physical measures like ambulation. The nurse's focus on early mobilization, alongside elastic stockings or leg exercises, aligns with evidence-based protocols (e.g., SCIP guidelines), significantly lowering PE incidence in perioperative care.
Question 2 of 5
A student nurse is developing a teaching plan for an adult patient with asthma. Which teaching point should have the highest priority in the plan of care that the student is developing?
Correct Answer: C
Rationale: For an adult with asthma, the highest priority teaching point is taking prescribed medications as scheduled, ensuring control of airway inflammation and bronchospasm. Inhaled corticosteroids (e.g., budesonide) and long-acting bronchodilators prevent exacerbations by maintaining baseline lung function, while rescue inhalers (e.g., albuterol) address acute symptoms adherence is critical, as non-compliance drives 60% of asthma hospitalizations. Increasing exertion gradually aids fitness but risks triggering attacks if uncontrolled. Changing filters reduces allergens (e.g., dust), a secondary environmental step. Avoiding goose-down pillows minimizes feather triggers, but this is less impactful than medication. The student nurse's focus on adherence detailing timing, technique (e.g., spacer), and side effects empowers the patient to prevent attacks, aligning with asthma action plans and long-term management success.
Question 3 of 5
A nurse is caring for a patient who has been admitted with an exacerbation of chronic bronchiectasis. The nurse should expect to assess the patient for which of the following clinical manifestations?
Correct Answer: A
Rationale: In a bronchiectasis exacerbation, copious sputum production is a primary clinical manifestation the nurse should expect, stemming from chronic bronchial dilation trapping purulent mucus. This hallmark often foul-smelling, voluminous (e.g., >30 mL/day) reflects recurrent infection and inflammation, driving symptoms like cough and dyspnea. Pain on inspiration suggests pleurisy or pneumothorax, not bronchiectasis's airway focus. Pigeon chest, a congenital deformity, isn't linked to this acquired condition. Dry cough contradicts bronchiectasis's wet, productive nature from mucus retention. The nurse's assessment quantifying sputum, noting color (e.g., green) informs care (e.g., drainage, antibiotics), aligning with bronchiectasis's pathophysiology and exacerbation management.
Question 4 of 5
An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients?
Correct Answer: B
Rationale: Preventing asthma exacerbations in adolescents hinges on educating them to recognize and avoid triggers e.g., allergens (pollen, pets), irritants (smoke), or exercise reducing inflammation and bronchospasm risk. This proactive strategy, central to asthma action plans (e.g., GINA), empowers teens to modify environments (e.g., using air filters) and preempt attacks, cutting hospital visits by up to 50%. Corticosteroids aren't rescue drugs albuterol is; inhaled steroids are maintenance, not acute. Alternative therapies (e.g., acupuncture) lack robust evidence for asthma control, secondary to standard care. Immunizations prevent infections like flu, which may trigger asthma, but aren't the primary prevention tool. The educator's focus on trigger education interactive, teen-friendly builds self-management skills, key for this age group's independence and long-term asthma control.
Question 5 of 5
The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Reasons for this intervention include
Correct Answer: C
Rationale: Diaphragmatic breathing, where the abdomen rises on inhalation, prevents atelectasis alveolar collapse post-surgery by fully inflating lungs. General anesthesia suppresses cough reflexes and reduces lung expansion, trapping mucus and risking atelectasis or pneumonia. This exercise, done every 2 hours, enhances ventilation, clearing airways. It minimally distracts from pain but doesn't manage it analgesics do. Healing time isn't directly shortened; oxygenation aids recovery indirectly. Thrombus prevention relies on leg exercises, not breathing, as venous stasis is circulatory. The nurse's encouragement reduces respiratory complications, ensuring oxygen saturation and lung function, a cornerstone of postoperative care per evidence-based practice.