NCLEX-PN
NCLEX Perioperative Nursing Questions Questions
Extract:
Question 1 of 5
The nurse identifies the nursing diagnosis 'risk for injury related to positioning' for the client in the operating room. Which nursing intervention should the nurse implement?
Correct Answer: B
Rationale: Padding elbows prevents pressure injuries during positioning, addressing the diagnosis. Cautery, warming pads, and medication checks are unrelated to positioning.
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 client diagnosed with appendicitis has undergone an appendectomy. At two (2) hours postoperative, the nurse takes the vital signs and notes T 102.6°F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority.
Order the Items
Source Container
Correct Answer: C,A,B,D,E
Rationale: 1) Elevate foot of bed (Trendelenburg for hypotension); 2) Notify HCP (fever, tachycardia, hypotension suggest sepsis); 3) Increase IV rate (bolus for hypovolemia); 4) Check dressing (assess bleeding); 5) Confirm antibiotics (treat infection).
Question 4 of 5
Which nursing intervention has the highest priority when preparing the client for a surgical procedure?
Correct Answer: C
Rationale: Preparing the incision site ensures asepsis, reducing infection risk, the highest priority. Padding, restraints, and room temperature are secondary.
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.