Saunders Comprehensive Review for
the NCLEX-RN Exam Pre-op, Intra-op,
Post-op
A 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 - ANSWER-2. Serous drainage
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.
Test-taking strategy: Use the process of elimination, noting the strategy words normal
finding. Recalling the signs of a wound infection and noting these strategy words will
direct you to option 2. Review the signs of a wound infection if you had difficulty with this
question.
When performing a surgical dressing change of a client's abdominal dressing, a nurse
notes an increase in the amount of drainage and separation of the incision line. The
underlying tissue is visible to the nurse. The nurse should do which of the following in
the initial care of this wound?
1. Leave the incision open to the air to dry the area.
2. Irrigate the wound and apply a sterile dry dressing.
3. Apply a sterile dressing soaked with normal saline.
4. Apply a sterile dressing soaked in providone-iodine (Betadine). - ANSWER-3. Apply a
sterile dressing soaked with normal saline.
Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs
and symptoms include increased drainage and the appearance of underlying tissues.
Dehiscence usually occurs 6 to 8 days after surgery. The client should be instructed to
remain quiet and avoid coughing or straining. The client should be positioned to prevent
further stress on the wound (semi-Fowler's). Sterile dressings soaked with sterile normal
saline should be used to cover the wound. The nurse must notify the physician after
applying the initial dressing to the wound. Options 1, 2, and 4 are incorrect.
, Test-taking strategy: Use the process of elimination. Eliminate option 1 first because
this action would dry the wound and also present a risk of infection to the underlying
tissues. Eliminate options 2 and 4 next because a dry dressing and a dressing soaked
with providone-iodine will irritate the exposed body tissues. Review initial nursing care
when dehiscence or evisceration occurs if you had difficulty with this question.
A nurse is monitoring the status of a postoperative client. The nurse would become
most concerned with which of the following signs that could indicate an evolving
complication?
1. Increasing restlessness
2. A negative Homans' sign
3. Hypoactive bowel sounds in all four quadrants
4. Blood pressure of 110/70 mm Hg and a pulse of 86 beats/min - ANSWER-1.
Increasing restlessness
Rationale: Increasing restlessness is a sign that requires continuous and close
monitoring because it could indicate a potential complication, such as hemorrhage,
shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86
beats/minute is within normal limits. Hypoactive bowel sounds heard in all four
quadrants are a normal occurrence, as is a negative Homans' sign (A positive Homans'
sign may indicate thrombophlebitis).
Test-Taking Strategy: Use the process of elimination and note the strategic word,
"most". Focus on the subject , "a manifestation of an evolving complication". Eliminate
each of the incorrect options because they are comparable or alike and are normal
expected findings. If you had difficulty with this question, review the normal expected
postoperative findings and the signs and symptoms of postoperative complications.
A nurse is reviewing a physician's order sheet for a preoperative client that states that
the client must be NPO after midnight. The nurse would telephone the physician to
clarify whether which of the following medications should be given to the client and not
withheld?
1. Ferrous sulfate
2. Prednisone (Deltasone)
3. Cycloenzaprine (Flexeril)
4. Conjugated estrogen (Premarin) - ANSWER-2. Prednisone (Deltasone)
Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause
adrenal atrophy, which reduces the ability of the body to withstand stress. When stress
is severe, corticosteroids are essential to life. Before and during surgery, dosages may
be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron
deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated
estrogen (Premarin) is an estrogen used for hormone replacement therapy in
postmenopausal women. These last three medications may be withheld before surgery
without undue effects on the client.
the NCLEX-RN Exam Pre-op, Intra-op,
Post-op
A 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 - ANSWER-2. Serous drainage
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.
Test-taking strategy: Use the process of elimination, noting the strategy words normal
finding. Recalling the signs of a wound infection and noting these strategy words will
direct you to option 2. Review the signs of a wound infection if you had difficulty with this
question.
When performing a surgical dressing change of a client's abdominal dressing, a nurse
notes an increase in the amount of drainage and separation of the incision line. The
underlying tissue is visible to the nurse. The nurse should do which of the following in
the initial care of this wound?
1. Leave the incision open to the air to dry the area.
2. Irrigate the wound and apply a sterile dry dressing.
3. Apply a sterile dressing soaked with normal saline.
4. Apply a sterile dressing soaked in providone-iodine (Betadine). - ANSWER-3. Apply a
sterile dressing soaked with normal saline.
Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs
and symptoms include increased drainage and the appearance of underlying tissues.
Dehiscence usually occurs 6 to 8 days after surgery. The client should be instructed to
remain quiet and avoid coughing or straining. The client should be positioned to prevent
further stress on the wound (semi-Fowler's). Sterile dressings soaked with sterile normal
saline should be used to cover the wound. The nurse must notify the physician after
applying the initial dressing to the wound. Options 1, 2, and 4 are incorrect.
, Test-taking strategy: Use the process of elimination. Eliminate option 1 first because
this action would dry the wound and also present a risk of infection to the underlying
tissues. Eliminate options 2 and 4 next because a dry dressing and a dressing soaked
with providone-iodine will irritate the exposed body tissues. Review initial nursing care
when dehiscence or evisceration occurs if you had difficulty with this question.
A nurse is monitoring the status of a postoperative client. The nurse would become
most concerned with which of the following signs that could indicate an evolving
complication?
1. Increasing restlessness
2. A negative Homans' sign
3. Hypoactive bowel sounds in all four quadrants
4. Blood pressure of 110/70 mm Hg and a pulse of 86 beats/min - ANSWER-1.
Increasing restlessness
Rationale: Increasing restlessness is a sign that requires continuous and close
monitoring because it could indicate a potential complication, such as hemorrhage,
shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86
beats/minute is within normal limits. Hypoactive bowel sounds heard in all four
quadrants are a normal occurrence, as is a negative Homans' sign (A positive Homans'
sign may indicate thrombophlebitis).
Test-Taking Strategy: Use the process of elimination and note the strategic word,
"most". Focus on the subject , "a manifestation of an evolving complication". Eliminate
each of the incorrect options because they are comparable or alike and are normal
expected findings. If you had difficulty with this question, review the normal expected
postoperative findings and the signs and symptoms of postoperative complications.
A nurse is reviewing a physician's order sheet for a preoperative client that states that
the client must be NPO after midnight. The nurse would telephone the physician to
clarify whether which of the following medications should be given to the client and not
withheld?
1. Ferrous sulfate
2. Prednisone (Deltasone)
3. Cycloenzaprine (Flexeril)
4. Conjugated estrogen (Premarin) - ANSWER-2. Prednisone (Deltasone)
Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause
adrenal atrophy, which reduces the ability of the body to withstand stress. When stress
is severe, corticosteroids are essential to life. Before and during surgery, dosages may
be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron
deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated
estrogen (Premarin) is an estrogen used for hormone replacement therapy in
postmenopausal women. These last three medications may be withheld before surgery
without undue effects on the client.
