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NUR 155 Test 2 (Crisis 2 NCLEX), FOUNDATIONS OF NURSING Comprehensive Exam Questions & Answers (With Rationales)-168. The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully dur...

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NUR 155 Test 2 (Crisis 2 NCLEX), FOUNDATIONS OF NURSING Comprehensive Exam
Questions & Answers (With Rationales)
168. The nurse has just reassessed the condition of a postoperative client who was
admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter
most carefully during the next hour?
1. Urinary output of 20 mL/hour
2. Temperature of 37.6 °C (99.6 °F)
3. Blood pressure of 100/70 mm Hg
4. Serous drainage on the surgical dressing - 1
Rationale:
Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output
of less than 30 mL for 2 consecutive hours should be reported to the health care provider.
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.

169. 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
Rationale:
Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli.
Pneumonia is the inflammation 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 to prevent pneumonia and atelectasis. Hypoxemia is an inadequate
concentration of oxygen in arterial blood. While close monitoring of the oxygen
saturation will help to detect hypoxemia, monitoring is not directly related to coughing
and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid
loss or overload, and surgical clients are often given intravenous fluids to prevent a
deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus

,occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or
more lobes of the lung; this is usually due to clot formation. Early ambulation and
administration of blood thinners helps to prevent this complication; however, it is not
related to coughing and deep-breathing techniques.

170. 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
Rationale:
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 to 8 hours (or longer as 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.

171. 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
Rationale:
Every effort should be made to obtain permission from a responsible family member to
perform surgery if the client is unable to sign the consent form. A telephone consent must
be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses
then sign the consent with the name of the family member, noting that an oral consent
was obtained. Consent is not informed if it is obtained from a client who is confused,
unconscious, mentally incompetent, or under the influence of sedatives. In an emergency,
a client may be unable to sign and family members may not be available. In this situation,
a health care provider is permitted legally to perform surgery without consent, but the
data in the question do not indicate an emergency. Options 1, 2, and 3 are not appropriate

,in this situation. Also, agency policies regarding informed consent should always be
followed.

172. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which
response by the nurse is most likely to stimulate further discussion between the client and
the nurse?
1. "If it's any help, everyone is nervous before surgery."
2. "I will be happy to explain the entire surgical procedure to you."
3. "Can you share with me what you've been told about your surgery?"
4. "Let me tell you about the care you'll receive after surgery and the amount of pain you
can anticipate." - 3
Rationale:
Explanations should begin with the information that the client knows. By providing the
client with individualized explanations of care and procedures, the nurse can assist the
client in handling anxiety and fear for a smooth preoperative experience. Clients who are
calm and emotionally prepared for surgery withstand anesthesia better and experience
fewer postoperative complications. Option 1 does not focus on the client's anxiety.
Explaining the entire surgical procedure may increase the client's anxiety. Option 4
avoids the client's anxiety and is focused on postoperative care.

173. The nurse is conducting preoperative teaching with a client about the use of an
incentive spirometer. The nurse should include which piece of information in discussions
with the client?
1. Inhale as rapidly as possible.
2. Keep a loose seal between the lips and the mouthpiece.
3. After maximum inspiration, hold the breath for 15 seconds and exhale.
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to
90 degrees. - 4
Rationale:
For optimal lung expansion with the incentive spirometer, the client should assume the
semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely
and tightly while the client inhales slowly, with a constant flow through the unit. The
breath should be held for 5 seconds before exhaling slowly.

174. The nurse has conducted preoperative teaching for a client scheduled for surgery in
1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The

, nurse determines that the client needs additional teaching if the client makes which
statement?
1. "Aspirin can cause bleeding after surgery."
2. "Aspirin can cause my ability to clot blood to be abnormal."
3. "I need to continue to take the aspirin until the day of surgery."
4. "I need to check with my health care provider about the need to stop the aspirin before
the scheduled surgery." - 3
Rationale:
Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery.
Aspirin has properties that can alter platelet aggregation and should be discontinued at
least 48 hours before surgery. However, the client should always check with his or her
health care provider regarding when to stop taking the aspirin when a surgical procedure
is scheduled. Options 1, 2, and 4 are accurate client statements.

175. The nurse assesses a client's surgical incision for signs of infection. Which finding
by the nurse would be interpreted as a normal finding at the surgical site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm, tender skin - 2
Rationale:
Serous drainage is an expected finding at a surgical site. The other options indicate signs
of wound infection. Signs and symptoms of infection include warm, red, and tender skin
around the incision. Wound infection usually appears 3 to 6 days after surgery. The client
also may have a fever and chills. Purulent material may exit from drains or from
separated wound edges. Infection may be caused by poor aseptic technique or a
contaminated wound before surgical exploration; existing client conditions such as
diabetes mellitus or immunocompromise may place the client at risk.

176. The nurse is monitoring the status of a postoperative client in the immediate
postoperative period. The nurse would become most concerned with which sign that
could indicate an evolving complication?
1. Increasing restlessness
2. A pulse of 86 beats/minute
3. Blood pressure of 110/70 mm Hg
4. Hypoactive bowel sounds in all 4 quadrants - 1

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