NCLEX-PN
NCLEX Perioperative Nursing Questions Questions
Extract:
Question 1 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 2 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 3 of 5
The client is in the lithotomy position during surgery. Which nursing intervention should be implemented to decrease a complication from the positioning?
Correct Answer: B
Rationale: Lowering legs sequentially prevents rapid blood pressure drops from venous pooling, reducing circulatory complications in lithotomy. Fluids, stretcher elevation, and epinephrine are unrelated.
Question 4 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.
Question 5 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).