NCLEX-PN
NCLEX Perioperative Nursing Questions Questions
Extract:
Question 1 of 5
The client has undergone an abdominal perineal resection of the colon for colon cancer with a left lower quadrant colostomy. Which interventions should the nurse implement? Select all that apply.
Correct Answer: A,B,D
Rationale: Stoma assessment monitors viability, coughing/deep breathing prevents atelectasis, and bowel sound checks assess GI function. HOB elevation is case-specific, and sparing pain medication risks undertreatment.
Question 2 of 5
Which statement would be an expected outcome for the postoperative client who had general anesthesia?
Correct Answer: B
Rationale: A pulse oximetry of 97% on room air indicates adequate oxygenation post-general anesthesia, a key outcome. Sitting, urine output, and sensation are secondary or unrelated.
Question 3 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 4 of 5
The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: Assessing breath sounds ensures airway patency and ventilation, the priority post-OR per ABCs. Oxygen, BP, and pulse oximetry follow airway assessment.
Question 5 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.