NCLEX Care of Surgical Patients Practice Exam
Which of the following is the primary concern for a nurse when caring for a postoperative patient?
A) Pain management
B) Early ambulation
C) Wound care
D) Prevention of infection
What is the purpose of a surgical consent form?
A) To ensure the patient understands the surgery’s risks and benefits
B) To authorize the physician to perform the surgery
C) To reduce the risk of surgical complications
D) To provide legal protection for the hospital
After a patient undergoes general anesthesia, what is the first priority in the postoperative phase?
A) Administering pain medication
B) Monitoring vital signs
C) Providing nutrition
D) Ambulation
Which action should the nurse take immediately after a patient comes out of surgery and is still under the effects of anesthesia?
A) Assist the patient to sit up
B) Administer pain medication
C) Assess the patient’s respiratory status
D) Provide the patient with fluids
The nurse is caring for a postoperative patient who has a Jackson-Pratt drain in place. The nurse should:
A) Empty the drain when it is half full
B) Change the drain every 12 hours
C) Monitor the drainage color and amount
D) Ensure the drain is disconnected from the tubing
What is the most important nursing intervention to prevent postoperative deep vein thrombosis (DVT)?
A) Early ambulation
B) Administering anticoagulants
C) Applying compression stockings
D) Encouraging fluid intake
Which of the following would be the best indication that a patient is at risk for postoperative complications?
A) A temperature of 100°F (37.8°C)
B) A heart rate of 80 bpm
C) A blood pressure of 120/80 mm Hg
D) A respiratory rate of 14 breaths per minute
What should the nurse do if a surgical wound begins to dehisce?
A) Apply a dry sterile dressing and notify the physician
B) Administer antibiotics immediately
C) Apply an ice pack to the wound
D) Encourage the patient to deep breathe
What is a priority nursing intervention for a patient with a history of smoking who is recovering from surgery?
A) Encouraging the patient to deep breathe
B) Providing increased fluids
C) Administering high doses of pain medication
D) Teaching the patient about smoking cessation
A patient is being discharged after a major abdominal surgery. Which of the following instructions is most important to provide?
A) Take pain medication only as needed
B) Follow up with the surgeon for a wound check
C) Avoid any strenuous activity for the first week
D) Eat high-protein foods to promote healing
What is the primary purpose of the preoperative assessment?
A) To assess the patient’s emotional response to surgery
B) To identify the patient’s physical and psychological health status
C) To inform the family about the procedure
D) To determine if the patient is able to pay for surgery
The nurse is caring for a patient who has had surgery and is receiving intravenous (IV) fluids. Which is the priority when assessing the patient?
A) Pain level
B) Fluid balance
C) Mobility
D) Nutritional status
When should the nurse administer a preoperative antibiotic?
A) Immediately after surgery
B) Within 30 minutes before incision
C) 1 hour after the procedure
D) When the patient begins to feel anxious
A patient is being prepared for surgery under regional anesthesia. Which of the following should the nurse inform the patient about?
A) They will be unconscious during the procedure
B) They will feel numbness in the area of surgery
C) They will not be able to move during the surgery
D) They will feel a burning sensation in their throat
A patient’s temperature is elevated 48 hours post-surgery. What is the most likely cause of the fever?
A) Postoperative infection
B) Normal response to surgery
C) Inflammatory response to the incision
D) Reaction to anesthesia
After surgery, the nurse finds a patient’s surgical dressing is saturated with blood. What is the priority action?
A) Reinforce the dressing with a clean, dry bandage
B) Notify the physician and prepare for possible surgical intervention
C) Administer pain medication
D) Monitor the patient’s vital signs
What is the most effective way to assess a patient’s airway following surgery?
A) Assess the patient’s skin color
B) Listen for breath sounds
C) Ask the patient to speak
D) Check the pulse oximeter reading
The nurse is caring for a postoperative patient who is experiencing nausea and vomiting. Which intervention should be prioritized?
A) Administering antiemetic medication
B) Encouraging deep breathing
C) Providing a cool compress to the forehead
D) Offering fluids to the patient
What is the main purpose of a postoperative chest X-ray?
A) To assess lung function
B) To determine the presence of blood clots
C) To evaluate the surgical site
D) To check for signs of infection
A patient is to be discharged after a laparoscopic cholecystectomy. Which of the following instructions should the nurse include?
A) “You may resume heavy activity after 48 hours.”
B) “It is normal to experience shoulder pain for several days.”
C) “You should avoid drinking fluids for the first 24 hours.”
D) “You must not shower for one week.”
A patient has an indwelling urinary catheter post-surgery. The nurse should monitor for:
A) Urine output less than 30 mL/hour
B) Dark brown urine
C) Fever with chills
D) Clear, non-odorous urine
Which is the most important factor for the nurse to monitor in a patient receiving postoperative narcotics?
A) Heart rate
B) Pain level
C) Respiratory rate
D) Blood pressure
The nurse should assess for which of the following signs that would indicate the need for a surgical wound dressing change?
A) No drainage for 24 hours
B) The wound is dry and intact
C) Purulent drainage or increased redness at the incision site
D) Clear drainage
The nurse is caring for a postoperative patient who is at risk for hypovolemic shock. Which intervention is most important?
A) Administer intravenous fluids
B) Monitor oxygen saturation levels
C) Apply warm compresses to the extremities
D) Monitor the patient for signs of infection
A patient is recovering from an appendectomy and is not passing gas. What should the nurse recommend?
A) Increase fluid intake
B) Use a heating pad to relieve discomfort
C) Ambulate the patient to encourage peristalsis
D) Administer an analgesic
What is the priority nursing intervention for a patient with a surgical wound infection?
A) Administer prescribed antibiotics
B) Provide comfort measures
C) Encourage the patient to eat high-protein foods
D) Assess for other signs of infection
What should the nurse assess before administering postoperative pain medication to a patient?
A) Vital signs and level of consciousness
B) Urinary output
C) Nutritional intake
D) Physical activity level
The nurse is caring for a patient who has just undergone surgery. The nurse should position the patient:
A) Flat in bed
B) In a high Fowler’s position
C) On the affected side
D) On the unaffected side
A patient is at risk for post-surgical complications due to obesity. What should the nurse prioritize in this patient’s care?
A) Assessing for signs of deep vein thrombosis
B) Ensuring adequate hydration
C) Providing a high-fiber diet
D) Ensuring proper wound care
Which is the best way to prevent postoperative pneumonia in a patient who has undergone surgery?
A) Encourage frequent coughing and deep breathing
B) Administer pain medications frequently
C) Increase fluid intake
D) Limit physical activity for the first 48 hours
The nurse is caring for a postoperative patient and notices that the surgical dressing is saturated with blood. What should the nurse do first?
A) Reinforce the dressing
B) Change the dressing and assess the wound
C) Notify the physician
D) Assess the patient’s vital signs
After a surgical procedure, a patient begins to cough and have difficulty breathing. What is the most likely cause of this complication?
A) Pneumonia
B) Atelectasis
C) Hypovolemic shock
D) Pulmonary embolism
The nurse is preparing a postoperative patient for discharge. What is the most important instruction the nurse should give the patient?
A) “Avoid lifting heavy objects for at least 2 weeks.”
B) “It is normal to experience swelling in the surgical area for several days.”
C) “Follow-up with your healthcare provider for a wound check.”
D) “You can resume all normal activities after a week.”
The nurse is caring for a postoperative patient who has developed hypothermia. What is the priority intervention?
A) Increase the room temperature
B) Apply warm blankets
C) Encourage oral fluids
D) Administer prescribed antibiotics
Which of the following is a common complication in the postoperative period for older adults?
A) Respiratory distress
B) Postoperative confusion or delirium
C) Excessive bleeding
D) Hyperthermia
A patient has just undergone abdominal surgery. The nurse should monitor for which of the following signs of a wound infection?
A) Increase in wound drainage and redness
B) Decrease in body temperature
C) Clear, odorless drainage
D) Improvement in appetite
A postoperative patient is at risk for thromboembolism. What is the most important nursing intervention?
A) Administer anticoagulants as prescribed
B) Encourage the patient to increase fluid intake
C) Apply anti-embolism stockings or pneumatic compression devices
D) Limit mobility to prevent strain
Which of the following should be monitored closely for a patient after receiving general anesthesia?
A) Electrolyte balance
B) Skin turgor
C) Respiratory status
D) Renal function
A nurse is caring for a postoperative patient who has a nasogastric tube in place. What is the most important nursing action?
A) Ensure that the tube is patent and draining
B) Encourage the patient to drink fluids regularly
C) Secure the tube to prevent dislodgement
D) Change the tube every 24 hours
Which postoperative complication is most common in patients who have undergone abdominal surgery?
A) Urinary retention
B) Bowel obstruction
C) Wound dehiscence
D) Pneumonia
The nurse is caring for a postoperative patient who is refusing to eat. Which of the following should the nurse do first?
A) Notify the healthcare provider
B) Assess the patient’s pain level
C) Offer a high-protein snack
D) Encourage the patient to take fluids
What is the first sign of postoperative hemorrhage that the nurse should monitor for?
A) Tachycardia
B) Elevated blood pressure
C) Bradycardia
D) Increased urine output
A postoperative patient is receiving opioid pain medication. Which of the following is a priority nursing intervention?
A) Encourage the patient to use an incentive spirometer
B) Increase the dosage of the opioid
C) Assess for signs of over-sedation and respiratory depression
D) Administer an antiemetic to prevent nausea
The nurse is assessing the postoperative patient’s incision site. Which of the following should be reported to the healthcare provider immediately?
A) Presence of a small amount of serous drainage
B) A slight increase in redness around the incision
C) Clear, odorless drainage
D) Sudden increase in wound drainage with purulent discharge
A postoperative patient has a Foley catheter in place. The nurse notes that the urine output is less than 30 mL/hr. What should the nurse do first?
A) Increase the intravenous fluids
B) Notify the healthcare provider
C) Assess for signs of dehydration
D) Check the catheter for kinks or obstructions
Which of the following is the most important consideration when preparing a patient for surgery?
A) Ensuring the patient’s consent is obtained
B) Administering preoperative antibiotics
C) Preparing the surgical site
D) Assessing for allergies to anesthesia
A postoperative patient is at risk for fluid volume deficit. The nurse should monitor for which of the following signs?
A) Tachycardia
B) Bradycardia
C) Hypertension
D) Decreased respiratory rate
A patient who underwent surgery is being discharged with a prescription for narcotics. The nurse should educate the patient about:
A) The risk of addiction and how to store medications safely
B) Discontinuing the narcotic once pain decreases
C) Avoiding all physical activity while on narcotics
D) Not taking any over-the-counter medications for pain
The nurse is caring for a patient who has had surgery and is experiencing moderate pain. What should the nurse do first?
A) Administer prescribed pain medication
B) Assess the pain using a pain scale
C) Encourage deep breathing exercises
D) Offer a distraction technique such as music
A postoperative patient has developed a fever 48 hours after surgery. What is the most likely cause of the fever?
A) Infection
B) Postoperative atelectasis
C) Blood clot formation
D) Anxiety and stress
The nurse is caring for a postoperative patient with a surgical wound. The nurse should be concerned if the patient develops which of the following?
A) Redness and warmth around the wound
B) Clear drainage from the wound
C) Sudden increase in pain around the wound
D) Slight swelling around the wound site
A patient undergoing a surgical procedure requires an epidural anesthetic. The nurse should monitor the patient for which complication?
A) Hypotension
B) Tachycardia
C) Fever
D) Vomiting
After a major surgery, a nurse is concerned about a patient’s risk of pressure ulcers. What is the best prevention strategy?
A) Apply a special mattress to relieve pressure
B) Turn the patient every 2 hours
C) Encourage fluid intake to improve skin integrity
D) Use moisturizing cream on dry skin
A patient recovering from surgery is ordered to have a complete blood count (CBC). What complication would the nurse most likely identify from this test after surgery?
A) Anemia
B) Leukocytosis
C) Hyperglycemia
D) Hypokalemia
What should the nurse monitor for a patient who has just had a thyroidectomy?
A) Hypothermia
B) Hypocalcemia
C) Hypertension
D) Hyperkalemia
The nurse is caring for a postoperative patient with an abdominal incision. The nurse should encourage the patient to:
A) Avoid deep breathing and coughing to prevent strain on the incision
B) Use an abdominal binder for extra support when coughing or moving
C) Sleep on the operative side to relieve discomfort
D) Keep the incision site open to air for faster healing
A postoperative patient has been given orders to ambulate within 24 hours after surgery. What is the most important benefit of early ambulation?
A) It prevents respiratory complications
B) It prevents infection
C) It promotes faster wound healing
D) It reduces the need for pain medications
A patient who underwent surgery 24 hours ago is experiencing shortness of breath. The nurse should first:
A) Administer oxygen
B) Listen to lung sounds
C) Assess vital signs
D) Notify the physician
After a patient undergoes laparoscopic surgery, what is the most common complaint?
A) Abdominal bloating
B) Chest pain
C) Headache
D) Nausea
A postoperative patient who has a nasogastric tube in place is exhibiting signs of fluid overload. The nurse should:
A) Check the tube for patency
B) Monitor intake and output
C) Administer diuretics as prescribed
D) Encourage fluid intake
A postoperative patient who had an appendectomy is experiencing abdominal distention and a lack of bowel sounds. What is the most likely cause of these symptoms?
A) Pneumonia
B) Atelectasis
C) Postoperative ileus
D) Wound infection
A nurse is preparing a patient for a major surgery. Which action is most important to reduce the risk of postoperative complications?
A) Administer preoperative antibiotics
B) Assess the patient’s nutritional status
C) Perform a full body assessment
D) Encourage the patient to fast for 24 hours
A patient has just undergone a cholecystectomy and is complaining of pain in the right shoulder. What should the nurse suspect as the cause?
A) Hemorrhage
B) Bile leakage
C) Gas used during laparoscopic surgery
D) Infection
A patient has just had a hip replacement. What is the most important action to prevent dislocation of the new hip?
A) Keep the affected leg in a neutral position
B) Avoid flexing the hip beyond 90 degrees
C) Encourage the patient to ambulate immediately
D) Use a heating pad to relax the hip muscles
A nurse is preparing to remove a postoperative patient’s surgical dressing. What is the most important consideration when performing this procedure?
A) Remove the dressing quickly to reduce discomfort
B) Ensure sterile technique to avoid contamination
C) Avoid touching the wound with gloved hands
D) Apply a new dressing immediately after removal
A postoperative patient is being discharged with instructions for wound care. Which of the following instructions is most important to include?
A) “You may remove the dressing whenever you feel it is uncomfortable.”
B) “Notify the healthcare provider if you notice increased redness or swelling at the incision site.”
C) “It is normal for the wound to drain clear fluid for several days.”
D) “You should not shower until the wound heals completely.”
A postoperative patient with a history of hypertension is receiving opioid pain medications. What is the nurse’s primary concern?
A) The risk of respiratory depression
B) The risk of hypertension due to pain
C) The patient will experience dizziness
D) The risk of developing a blood clot
A patient recovering from surgery has developed a fever and a cough. Which of the following complications should the nurse suspect?
A) Pneumonia
B) Wound infection
C) Deep vein thrombosis
D) Urinary tract infection
Which of the following should be included in the care plan for a postoperative patient at risk for fluid volume deficit?
A) Monitor for signs of dehydration
B) Restrict all fluid intake for the first 24 hours
C) Encourage caffeine-rich beverages to increase alertness
D) Administer large volumes of fluid quickly
A patient has undergone abdominal surgery. Which of the following is a priority nursing assessment in the first 24 hours after surgery?
A) Monitor for signs of gastrointestinal bleeding
B) Assess respiratory status and oxygenation
C) Assess for signs of urinary retention
D) Monitor for signs of hyperglycemia
A postoperative patient is at risk for deep vein thrombosis (DVT). What intervention is most important in preventing this complication?
A) Administering anticoagulants as prescribed
B) Encouraging the patient to use an incentive spirometer
C) Applying anti-embolism stockings
D) Limiting the patient’s activity until healing is complete
After a patient has surgery, they complain of severe pain at the surgical site. The nurse should first:
A) Administer the prescribed pain medication
B) Assess the wound for signs of infection
C) Increase the patient’s fluid intake
D) Reposition the patient for comfort
The nurse is caring for a patient with a urinary catheter who is 24 hours postoperative. What is the nurse’s priority action if the catheter becomes dislodged?
A) Notify the healthcare provider immediately
B) Assess the patient for signs of bleeding
C) Attempt to reinsert the catheter
D) Monitor the patient for signs of infection
A postoperative patient has an elevated white blood cell count and is experiencing redness and warmth at the surgical site. What is the nurse’s priority action?
A) Notify the healthcare provider about a possible infection
B) Administer prescribed antibiotics
C) Encourage the patient to increase fluid intake
D) Change the dressing and apply an ice pack
A patient has undergone spinal surgery and is recovering in the post-anesthesia care unit (PACU). What is the most important nursing intervention for this patient?
A) Assess for signs of wound infection
B) Monitor for complications related to immobility
C) Ensure adequate pain management
D) Encourage the patient to cough and deep breathe
The nurse is assessing a postoperative patient who has been on bed rest for several days. What is the nurse’s priority action to prevent complications?
A) Encourage the patient to drink fluids
B) Monitor the patient’s oxygen saturation levels
C) Encourage early ambulation and leg exercises
D) Administer pain medications as prescribed
A postoperative patient is being discharged with a prescription for antibiotics. What should the nurse emphasize about the use of antibiotics?
A) “You should stop taking the antibiotics if you feel better.”
B) “Finish the entire course of antibiotics as prescribed, even if you feel better.”
C) “You should take antibiotics only if you develop a fever.”
D) “You should double the dose if you miss one.”
A postoperative patient is experiencing difficulty breathing. What is the most important intervention for the nurse to perform?
A) Elevate the head of the bed to facilitate breathing
B) Administer pain medication to reduce discomfort
C) Provide a warm compress to the chest
D) Apply oxygen and assess vital signs
A nurse is caring for a postoperative patient with a nasogastric tube. What is the nurse’s priority action in managing the tube?
A) Ensure the tube is properly secured to prevent dislodgement
B) Encourage the patient to drink fluids frequently
C) Monitor the tube for signs of occlusion
D) Remove the tube as soon as possible
A postoperative patient is experiencing excessive bleeding from the surgical site. The nurse should first:
A) Apply pressure to the wound site
B) Call the healthcare provider
C) Assess the patient’s vital signs
D) Change the dressing to check the amount of bleeding
A postoperative patient with a history of hypertension is at risk for wound dehiscence. The nurse should:
A) Administer antihypertensive medications as prescribed
B) Apply a dressing with increased absorbency
C) Encourage the patient to stay in bed and avoid movement
D) Ensure the patient follows a low-sodium diet
A nurse is caring for a patient who had surgery to remove a tumor. The patient is worried about the pathology results. What is the best way for the nurse to respond?
A) “Don’t worry. The doctor will explain everything to you.”
B) “It’s normal to feel anxious. The results will be available soon.”
C) “I understand your concerns, and I will ensure that the doctor speaks with you about the results.”
D) “The results should be fine, don’t worry.”
A postoperative patient with a history of smoking is at increased risk for which of the following complications?
A) Hypotension
B) Pneumonia
C) Dehydration
D) Bowel obstruction
The nurse is caring for a postoperative patient who has received an epidural analgesic. What is the most important action the nurse should take?
A) Monitor the patient for signs of respiratory depression
B) Encourage the patient to take frequent deep breaths
C) Administer oral pain medications as prescribed
D) Perform passive range of motion exercises
A postoperative patient is recovering from general anesthesia. The nurse should assess the patient for which of the following?
A) Fluid retention
B) Hypovolemia
C) Airway patency and oxygenation
D) Hyperglycemia
The nurse is caring for a postoperative patient who has been given opioid analgesics. What is the most important action for the nurse to monitor?
A) The patient’s level of sedation
B) The patient’s blood pressure
C) The patient’s intake and output
D) The patient’s temperature
A patient who underwent surgery 6 hours ago suddenly becomes restless, tachycardic, and hypotensive. What is the nurse’s priority action?
A) Administer pain medication
B) Reassess vital signs and perform a head-to-toe assessment
C) Apply oxygen and notify the healthcare provider
D) Perform a neurovascular check on the extremities
A postoperative patient has developed a blood clot. What is the most appropriate nursing intervention?
A) Encourage the patient to lie flat
B) Apply warm compresses to the affected area
C) Elevate the affected limb and apply anti-embolism stockings
D) Administer an anticoagulant as prescribed
A patient undergoing a surgical procedure is given general anesthesia. What is the most important thing to monitor during the procedure?
A) Blood pressure
B) Electrolyte balance
C) Respiratory status
D) Body temperature
A postoperative patient develops confusion and agitation. What should the nurse do first?
A) Administer a sedative
B) Check the patient’s vital signs
C) Encourage the patient to drink fluids
D) Ensure the patient is properly positioned
A patient undergoing abdominal surgery is at risk for infection. What is the best intervention to reduce this risk?
A) Administer prophylactic antibiotics before surgery
B) Encourage deep breathing exercises postoperatively
C) Apply a heat pack to the surgical site
D) Limit the patient’s fluid intake
A nurse observes that a postoperative patient has a low-grade fever on the second day after surgery. What is the most likely cause?
A) Surgical site infection
B) Atelectasis
C) Urinary tract infection
D) Deep vein thrombosis
A nurse is educating a patient on how to use an incentive spirometer. What is the primary goal of this device?
A) Improve oxygen saturation
B) Prevent atelectasis
C) Reduce respiratory rate
D) Enhance abdominal muscle strength
A nurse notes that a postoperative patient has a blood pressure of 80/50 mmHg and a weak pulse. What should the nurse suspect?
A) Hemorrhage
B) Deep vein thrombosis
C) Pulmonary embolism
D) Dehydration
A nurse is caring for a postoperative patient who reports nausea. What is the nurse’s best action?
A) Offer the patient sips of water
B) Administer prescribed antiemetic medication
C) Encourage the patient to ambulate
D) Apply a cold compress to the patient’s forehead
A nurse is teaching a patient about wound care following abdominal surgery. What should the patient report immediately?
A) Slight redness around the incision
B) A temperature of 37.5°C (99.5°F)
C) Drainage with a foul odor
D) Mild swelling near the incision
After knee surgery, a patient is reluctant to perform physical therapy. What should the nurse do?
A) Explain the risks of immobility and complications
B) Force the patient to complete therapy
C) Postpone therapy until the patient feels ready
D) Provide additional pain medication
A nurse is monitoring a patient recovering from general anesthesia. What is the most critical parameter to assess?
A) Pain level
B) Blood pressure
C) Oxygen saturation
D) Level of consciousness
A patient recovering from abdominal surgery is at risk for paralytic ileus. Which of the following is a key nursing intervention?
A) Encourage early ambulation
B) Provide a high-fiber diet
C) Limit oral fluid intake
D) Administer enemas as prescribed
A postoperative patient develops redness, swelling, and warmth at the IV site. What should the nurse do first?
A) Apply a cold compress
B) Remove the IV catheter
C) Elevate the affected limb
D) Document the findings and reassess later
A patient is experiencing significant pain at the surgical site. What is the nurse’s priority action?
A) Assess the pain level and administer prescribed analgesics
B) Notify the healthcare provider immediately
C) Reposition the patient and reassess later
D) Apply a warm compress to the site
A postoperative patient has not urinated for 8 hours after surgery. What should the nurse do first?
A) Administer diuretics
B) Assess the bladder for distention
C) Insert a urinary catheter
D) Encourage the patient to drink fluids
A patient is recovering from surgery and is at risk for hypovolemic shock. Which sign would the nurse expect to see first?
A) Elevated blood pressure
B) Increased heart rate
C) Warm, flushed skin
D) Bradycardia
A postoperative patient reports shortness of breath and chest pain. What should the nurse suspect?
A) Pneumonia
B) Pulmonary embolism
C) Heart attack
D) Atelectasis
Which intervention is most effective in preventing venous thromboembolism in a postoperative patient?
A) Administer anticoagulants as prescribed
B) Encourage the patient to drink fluids
C) Monitor the patient’s oxygen levels
D) Restrict the patient’s movement
A nurse is caring for a postoperative patient who suddenly begins to vomit. What is the priority action?
A) Assess for bowel obstruction
B) Turn the patient onto their side to prevent aspiration
C) Provide a basin and document the amount
D) Notify the healthcare provider
A postoperative patient is reluctant to cough due to pain. What can the nurse do to assist?
A) Provide a pillow for splinting during coughing
B) Avoid encouraging coughing to prevent discomfort
C) Offer the patient a cold drink before coughing
D) Encourage shallow breathing instead of deep breaths
A nurse is caring for a patient recovering from hip replacement surgery. What is the priority intervention?
A) Prevent hip flexion greater than 90 degrees
B) Restrict fluid intake
C) Encourage the patient to sit cross-legged
D) Apply continuous heat therapy
A postoperative patient with a surgical wound is being discharged. Which statement indicates a need for further teaching?
A) “I will wash my hands before changing the dressing.”
B) “I should report any drainage with a foul smell.”
C) “I can soak in a tub to help clean the incision.”
D) “I will notify my doctor if the area becomes red or swollen.”
A nurse is caring for a postoperative patient who is drowsy and difficult to arouse. What is the most important action?
A) Administer naloxone as prescribed
B) Increase the oxygen flow rate
C) Assess the patient’s blood glucose level
D) Notify the healthcare provider
A patient recovering from bowel surgery reports feeling bloated and has no bowel sounds. What is the nurse’s best action?
A) Notify the healthcare provider immediately
B) Encourage early ambulation
C) Insert a nasogastric tube as prescribed
D) Provide a high-fiber diet
A postoperative patient is restless and has a respiratory rate of 30 breaths per minute. What is the nurse’s priority action?
A) Administer pain medication
B) Assess the patient’s oxygen saturation
C) Call the rapid response team
D) Encourage the patient to rest
A patient recovering from a surgical procedure is prescribed a clear liquid diet. Which item is appropriate?
A) Coffee with cream
B) Orange juice
C) Chicken broth
D) Mashed potatoes
A nurse is providing postoperative teaching to a patient who will be using patient-controlled analgesia (PCA). What should the nurse emphasize?
A) “Only press the button when you are experiencing pain.”
B) “You can press the button as often as you like.”
C) “The machine will administer medication automatically.”
D) “Only a nurse should press the PCA button for you.”
A postoperative patient reports severe pain despite receiving pain medication. What is the nurse’s best action?
A) Notify the healthcare provider
B) Administer a second dose of the pain medication
C) Perform a full assessment of the patient
D) Reposition the patient for comfort
A patient is receiving epidural analgesia postoperatively. What is the most critical assessment?
A) Heart rate
B) Respiratory status
C) Pain level
D) Bowel sounds
A nurse is monitoring a postoperative patient who develops a sudden onset of confusion. What should the nurse suspect first?
A) Hypoxia
B) Pain medication overdose
C) Electrolyte imbalance
D) Urinary retention
A postoperative patient is receiving oxygen therapy. What is the primary purpose of this intervention?
A) Prevent infection
B) Enhance tissue perfusion
C) Prevent atelectasis
D) Reduce fluid retention
A nurse assesses a patient’s surgical wound and notes a separation of the wound edges. What is the term for this complication?
A) Evisceration
B) Dehiscence
C) Fistula
D) Hematoma
A patient’s wound dressing is saturated with blood within the first hour after surgery. What is the nurse’s priority action?
A) Reinforce the dressing and notify the surgeon
B) Remove the dressing and inspect the wound
C) Apply a tourniquet above the wound site
D) Document the finding and reassess in 30 minutes
A nurse is caring for a patient following abdominal surgery. The patient reports feeling something “give way” at the incision site, and the nurse observes organ protrusion. What is the nurse’s priority action?
A) Cover the area with a sterile, moist dressing
B) Reinsert the protruding organ
C) Call the rapid response team
D) Apply a dry dressing and reposition the patient
A nurse is preparing a postoperative patient for discharge. What is the most important teaching point to prevent infection?
A) Avoid bathing or showering for two weeks
B) Follow proper hand hygiene and wound care instructions
C) Take antibiotics only if symptoms worsen
D) Keep the incision uncovered for better healing
A patient is at risk for deep vein thrombosis (DVT) after surgery. Which intervention is most effective in reducing this risk?
A) Encourage the use of compression stockings
B) Provide fluids to prevent dehydration
C) Administer pain medication as prescribed
D) Place the patient on strict bed rest
A nurse is monitoring a patient 24 hours after surgery and notes decreased breath sounds on the left side. What is the most likely cause?
A) Atelectasis
B) Pulmonary embolism
C) Pneumonia
D) Pleural effusion
A postoperative patient complains of gas pain. What is the best nursing intervention?
A) Administer a laxative
B) Encourage early ambulation
C) Offer carbonated beverages
D) Provide a heating pad
A nurse is caring for a patient with a PCA pump. What is the most important parameter to monitor?
A) Respiratory rate
B) Blood pressure
C) Pain score
D) Heart rate
A patient reports pain at the incision site that worsens with movement. What should the nurse assess for?
A) Infection
B) Deep vein thrombosis
C) Dehiscence
D) Pulmonary embolism
A nurse is assessing a patient recovering from a thyroidectomy. Which sign indicates a potential complication?
A) Increased appetite
B) Difficulty speaking
C) Muscle twitching and tingling
D) Increased urine output
A patient has a drain placed during surgery. What is the nurse’s priority intervention?
A) Flush the drain daily with saline
B) Maintain the drain in a dependent position
C) Assess and document the amount and type of drainage regularly
D) Remove the drain if the patient reports discomfort
A nurse is caring for a postoperative patient with a history of sleep apnea. What is the nurse’s priority action?
A) Administer oxygen as prescribed
B) Encourage the patient to ambulate frequently
C) Elevate the head of the bed during sleep
D) Use a continuous positive airway pressure (CPAP) device
A patient recovering from surgery is prescribed a full liquid diet. Which food is appropriate?
A) Mashed potatoes
B) Cream of chicken soup
C) Toast with butter
D) Fresh fruit
A postoperative patient has diminished bowel sounds and no flatus. What is the nurse’s best action?
A) Encourage the patient to drink clear fluids
B) Encourage ambulation to stimulate peristalsis
C) Administer a stool softener
D) Increase the patient’s fiber intake
A nurse is caring for a patient with a Jackson-Pratt drain. How should the nurse maintain the drain?
A) Secure it to the patient’s gown below the wound
B) Keep it fully expanded to maximize drainage
C) Irrigate it with sterile water every 4 hours
D) Empty and compress it to restore suction
A nurse observes a postoperative patient coughing up pink, frothy sputum. What should the nurse suspect?
A) Pulmonary embolism
B) Congestive heart failure
C) Pneumothorax
D) Bronchitis
A patient develops a fever, hypotension, and chills 2 days postoperatively. What is the nurse’s priority action?
A) Increase fluid intake
B) Notify the healthcare provider
C) Administer antipyretics
D) Encourage the patient to ambulate
A postoperative patient is at risk for hypothermia. Which intervention is most effective in maintaining normothermia?
A) Apply warm blankets
B) Increase room temperature
C) Offer warm fluids
D) Encourage physical activity
A patient has a penrose drain following surgery. How should the nurse care for it?
A) Secure it to the skin with tape
B) Shorten the drain daily
C) Keep it in a dependent position
D) Empty it every shift
A patient reports tingling in their fingers after receiving a blood transfusion during surgery. What is the most likely cause?
A) Hypocalcemia
B) Hyperkalemia
C) Infection
D) Dehydration
A nurse is teaching a patient about preventing pneumonia postoperatively. Which action should be emphasized?
A) Use the incentive spirometer regularly
B) Restrict fluid intake
C) Avoid coughing to prevent pain
D) Lie flat while resting
A postoperative patient is on opioid analgesics. What is a priority nursing assessment?
A) Urine output
B) Pain level
C) Respiratory status
D) Bowel sounds
Questions and Answers for Study Guide
Question 1:
Discuss the nursing interventions to prevent postoperative complications related to respiratory function.
Answer:
Postoperative respiratory complications, such as atelectasis and pneumonia, can significantly impact patient recovery. Nursing interventions to prevent these complications include:
- Encouraging Deep Breathing and Coughing Exercises: Patients should perform these exercises every 1–2 hours while awake to promote lung expansion and clear secretions.
- Incentive Spirometry: This device helps patients achieve maximum lung inflation, reducing the risk of atelectasis.
- Frequent Position Changes: Repositioning the patient at least every 2 hours prevents stasis of secretions and improves lung ventilation.
- Early Ambulation: Mobilizing the patient as early as possible promotes effective lung function and circulation.
- Adequate Pain Management: Controlling pain ensures patients can breathe deeply and cough effectively without hesitation.
- Oxygen Therapy: Supplemental oxygen may be used to maintain adequate oxygen saturation levels.
- Monitoring Respiratory Status: Regular assessment of respiratory rate, oxygen saturation, and breath sounds ensures early detection of complications.
By implementing these interventions, nurses play a crucial role in minimizing the risk of postoperative respiratory issues.
Question 2:
Explain the steps a nurse should take if a patient experiences wound dehiscence postoperatively.
Answer:
Wound dehiscence, the partial or complete separation of surgical wound edges, is a serious complication. The nurse’s response should include the following steps:
- Stay Calm and Reassure the Patient: Keeping the patient calm reduces further stress on the wound.
- Position the Patient Appropriately: Place the patient in a low Fowler’s position with knees slightly flexed to reduce strain on the abdomen.
- Cover the Wound: Apply sterile, saline-moistened dressings to the wound to protect it and prevent infection.
- Avoid Repositioning the Protruding Organs: If evisceration is present, do not attempt to push the organs back inside.
- Notify the Surgeon Immediately: Prompt communication with the healthcare provider is critical for timely intervention.
- Monitor Vital Signs: Assess for signs of shock, such as hypotension or tachycardia, and be prepared to initiate resuscitative measures if necessary.
- Prepare for Surgery: The patient may require emergency surgery to repair the wound. Ensure all preoperative preparations are completed.
Effective management of wound dehiscence minimizes further complications and ensures patient safety.
Question 3:
What is the role of pain management in the care of surgical patients, and how can nurses ensure it is effective?
Answer:
Pain management is a critical component of postoperative care, as uncontrolled pain can hinder recovery. The nurse’s role includes:
- Assessing Pain Regularly: Use pain scales to evaluate the patient’s pain intensity and location.
- Administering Prescribed Analgesics: Ensure timely administration of medications such as opioids or non-opioid analgesics.
- Monitoring for Side Effects: Watch for adverse effects like respiratory depression or gastrointestinal upset and intervene as needed.
- Providing Non-Pharmacological Interventions: Techniques such as relaxation exercises, guided imagery, and cold/heat applications can complement medication.
- Educating the Patient: Explain the importance of pain management in recovery and encourage patients to report pain early.
- Collaborating with the Care Team: Work with the healthcare provider to adjust pain regimens if the patient’s pain is uncontrolled.
- Promoting Mobility: Adequate pain control allows for early ambulation, which prevents complications like deep vein thrombosis.
Effective pain management enhances the patient’s ability to participate in recovery activities and reduces the risk of complications.
Question 4:
Analyze the significance of early ambulation in postoperative recovery.
Answer:
Early ambulation is a cornerstone of postoperative recovery, offering numerous physical and psychological benefits:
- Prevention of Deep Vein Thrombosis (DVT): Mobilization enhances circulation, reducing the risk of blood clots.
- Improved Respiratory Function: Walking encourages deep breathing, preventing atelectasis and pneumonia.
- Enhanced Gastrointestinal Function: Ambulation stimulates bowel motility, reducing the risk of constipation and ileus.
- Promotion of Wound Healing: Increased circulation ensures adequate oxygen and nutrients are delivered to tissues.
- Reduction in Pain and Stiffness: Movement alleviates joint stiffness and may reduce postoperative pain.
- Psychological Benefits: Ambulation boosts morale and fosters independence, which are critical for overall well-being.
- Decreased Length of Hospital Stay: Early mobility accelerates recovery, enabling patients to be discharged sooner.
Nurses play a vital role by educating patients about the importance of ambulation, providing assistance as needed, and addressing any barriers to mobility.
Question 5:
Describe how a nurse can identify and address potential signs of infection in a postoperative patient.
Answer:
Postoperative infections can delay recovery and increase morbidity. Nurses must monitor for the following signs and intervene accordingly:
- Signs of Infection: Common indicators include redness, swelling, warmth, and purulent drainage at the surgical site, as well as systemic symptoms like fever and chills.
- Wound Assessment: Regular inspection of the incision for changes in appearance or delayed healing is essential.
- Monitoring Laboratory Values: Elevated white blood cell counts may indicate infection.
- Maintaining Aseptic Technique: Proper hand hygiene and sterile dressing changes prevent contamination.
- Encouraging Hydration and Nutrition: Adequate fluid intake and a balanced diet support immune function and tissue repair.
- Administering Antibiotics: If prescribed, ensure the timely administration of antibiotics to combat infection.
- Reporting to the Provider: Notify the healthcare provider promptly if infection is suspected.
Through vigilance and proactive care, nurses help prevent and manage postoperative infections effectively.