Preoperative Phase
1. A client scheduled for surgery states they had breakfast three
hours ago. What is the nurse's best action?
A. Inform the client that this is acceptable.
B. Notify the surgical team immediately.
C. Instruct the client not to eat anything else.
D. Administer an antiemetic as prescribed.
Answer: B. Notify the surgical team immediately.
Rationale: NPO status must be maintained to reduce the risk of aspiration
during surgery.
2. Before surgery, a client states they do not understand the
procedure. What is the nurse's priority action?
A. Explain the procedure in simple terms.
B. Notify the surgeon about the client’s concern.
C. Reassure the client that the surgeon will explain everything.
D. Postpone the surgery until the client consents.
Answer: B. Notify the surgeon about the client’s concern.
Rationale: It is the surgeon’s responsibility to ensure the client is informed
before obtaining consent.
3. Which preoperative assessment finding requires immediate
intervention?
A. Blood pressure of 140/90
B. Hemoglobin of 10 g/dL
C. Potassium level of 2.9 mEq/L
D. Fasting blood glucose of 120 mg/dL
Answer: C. Potassium level of 2.9 mEq/L
Rationale: Low potassium can cause life-threatening cardiac dysrhythmias.
4. The nurse is preparing a client for surgery. Which action takes
priority?
A. Ensuring all preoperative forms are signed.
B. Administering preoperative medications.
C. Removing jewelry and prosthetics.
D. Verifying the surgical site with the client.
Answer: D. Verifying the surgical site with the client.
Rationale: Confirming the surgical site ensures safety and prevents wrong-
site surgery.
, 5. What is the purpose of a preoperative CHG (chlorhexidine
gluconate) bath?
A. Prevent postoperative pneumonia.
B. Decrease the risk of surgical site infection.
C. Enhance the healing of the surgical site.
D. Remove all skin oils for better adhesion of dressings.
Answer: B. Decrease the risk of surgical site infection.
Rationale: CHG reduces the microbial load on the skin to prevent
infections.
Intraoperative Phase
6. A nurse notices that a member of the surgical team breaks
sterility. What is the best response?
A. Address the breach after the procedure is complete.
B. Document the observation in the client’s chart.
C. Notify the surgeon immediately.
D. Ask the team member to leave the sterile field.
Answer: C. Notify the surgeon immediately.
Rationale: Immediate action prevents contamination and maintains
sterility.
7. A client undergoing surgery develops malignant hyperthermia.
What is the nurse’s priority intervention?
A. Administer dantrolene.
B. Stop the surgery immediately.
C. Apply ice packs to the client’s chest.
D. Notify the family.
Answer: A. Administer dantrolene.
Rationale: Dantrolene is the treatment of choice to reverse malignant
hyperthermia.
8. Which safety measure is part of the Universal Protocol in the
operating room?
A. Performing a skin test for allergies.
B. Confirming the correct procedure and site during a "time-out."
1. A client scheduled for surgery states they had breakfast three
hours ago. What is the nurse's best action?
A. Inform the client that this is acceptable.
B. Notify the surgical team immediately.
C. Instruct the client not to eat anything else.
D. Administer an antiemetic as prescribed.
Answer: B. Notify the surgical team immediately.
Rationale: NPO status must be maintained to reduce the risk of aspiration
during surgery.
2. Before surgery, a client states they do not understand the
procedure. What is the nurse's priority action?
A. Explain the procedure in simple terms.
B. Notify the surgeon about the client’s concern.
C. Reassure the client that the surgeon will explain everything.
D. Postpone the surgery until the client consents.
Answer: B. Notify the surgeon about the client’s concern.
Rationale: It is the surgeon’s responsibility to ensure the client is informed
before obtaining consent.
3. Which preoperative assessment finding requires immediate
intervention?
A. Blood pressure of 140/90
B. Hemoglobin of 10 g/dL
C. Potassium level of 2.9 mEq/L
D. Fasting blood glucose of 120 mg/dL
Answer: C. Potassium level of 2.9 mEq/L
Rationale: Low potassium can cause life-threatening cardiac dysrhythmias.
4. The nurse is preparing a client for surgery. Which action takes
priority?
A. Ensuring all preoperative forms are signed.
B. Administering preoperative medications.
C. Removing jewelry and prosthetics.
D. Verifying the surgical site with the client.
Answer: D. Verifying the surgical site with the client.
Rationale: Confirming the surgical site ensures safety and prevents wrong-
site surgery.
, 5. What is the purpose of a preoperative CHG (chlorhexidine
gluconate) bath?
A. Prevent postoperative pneumonia.
B. Decrease the risk of surgical site infection.
C. Enhance the healing of the surgical site.
D. Remove all skin oils for better adhesion of dressings.
Answer: B. Decrease the risk of surgical site infection.
Rationale: CHG reduces the microbial load on the skin to prevent
infections.
Intraoperative Phase
6. A nurse notices that a member of the surgical team breaks
sterility. What is the best response?
A. Address the breach after the procedure is complete.
B. Document the observation in the client’s chart.
C. Notify the surgeon immediately.
D. Ask the team member to leave the sterile field.
Answer: C. Notify the surgeon immediately.
Rationale: Immediate action prevents contamination and maintains
sterility.
7. A client undergoing surgery develops malignant hyperthermia.
What is the nurse’s priority intervention?
A. Administer dantrolene.
B. Stop the surgery immediately.
C. Apply ice packs to the client’s chest.
D. Notify the family.
Answer: A. Administer dantrolene.
Rationale: Dantrolene is the treatment of choice to reverse malignant
hyperthermia.
8. Which safety measure is part of the Universal Protocol in the
operating room?
A. Performing a skin test for allergies.
B. Confirming the correct procedure and site during a "time-out."
