NCLEX-PN
NCLEX Perioperative Nursing Questions Questions
Extract:
Question 1 of 5
The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply.
Correct Answer: B,D
Rationale: Tachycardia, hyperthermia, and muscle stiffness suggest malignant hyperthermia; ice packs cool the body, and dantrolene reverses the condition. Back rubs, ice slush, and warming blankets are inappropriate.
Question 2 of 5
Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain?
Correct Answer: C
Rationale: Checking allergies prevents adverse reactions, the highest safety priority. Vital signs, timing, and pain discussion follow.
Question 3 of 5
The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply.
Correct Answer: B,D,E
Rationale: Coughing/deep breathing prevents atelectasis, pain management enhances recovery, and PACU education reduces anxiety. Passive ROM is postoperative, and meals are not allowed in PACU.
Question 4 of 5
The circulating nurse notes a discrepancy in the needle count. What intervention should the nurse implement first?
Correct Answer: A
Rationale: Informing the team prompts a recount and investigation, the first step to prevent retained needles. Assuming errors, ordering x-rays, or reporting are premature.
Question 5 of 5
The postoperative client complains of hearing a 'popping sound' and feeling 'something opening' when ambulating in the room. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: A popping sound and opening sensation suggest dehiscence or evisceration; assessing and covering with a moist dressing stabilizes the site, the first step. Notification and surgery prep follow, and dismissing the symptom is unsafe.