Perioperative Nursing Care NCLEX Questions and Answers Rated A

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Perioperative Nursing Care NCLEX Questions and Answers Rated A The nurse has just reassessed the condition of a post-operative client who was admitted 1 hour ago to the surgical unit. The nurse pla... ns to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hr 2. Temperature of 37.6 C (99.6 F) 3. Blood pressure of 100/70 mmHg 4. Serous drainage on the surgical dressing ✔✔1. Urinary output of 20 mL/hr Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 Ml for 2 consecutive hours should be reported to the surgeon. A temperature higher than 37.7 C (100 F) or lower than 36.1 C (97 F) and a falling systolic blood pressure, lower than 90 mm HG, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal. The nurse is teaching a client about coughing and deep breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism." ✔✔1. "Use of an incentive spirometer will help prevent pneumonia." Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps prevent pneumonia and atelectasis. The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours 3. Have the client void immediately before going into surgery 4. Report immediately any slight increase in blood pressure or pulse ✔✔3. Have the client void immediately before going into surgery The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6-8 hours (or longer if prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety. A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery 2. Have the charge nurse sign the informed consent immediately 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from a family member, following agency policy ✔✔4. Obtain a telephone consent from a family member, following agency policy Every effort should be made to obtain permission [Show More]

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