NSG3130 Fundamental II ACTUAL EXAM
2024/2025 | Official Blueprint Replica |
Verified Q&A | Pass Guaranteed - A+
Graded
SECTION: Perioperative Nursing (12 Questions)
Unfolding Clinical Scenario: Postoperative Patient
A 68-year-old client underwent open cholecystectomy under general anesthesia and is
being transferred to the surgical unit.
Q1: During the preoperative assessment, the client reports taking warfarin 5 mg daily.
Which action should the nurse take first?
A. Document the medication and continue preop preparation
B. Notify the surgeon and anesthesia provider [CORRECT]
C. Instruct the client to take the dose the morning of surgery
D. Administer vitamin K prophylactically
Correct Answer: B
Rationale: Correct because warfarin increases bleeding risk during surgery and requires
coordination with the surgeon and anesthesia provider regarding discontinuation
timing. Priority is communication for patient safety.
Q2: On postoperative day 1, the client reports incisional pain rated 6/10 and refuses to
ambulate. Which response by the nurse is most appropriate?
A. "Ambulation will increase your pain and should be delayed."
B. "Early ambulation reduces complications and I will medicate you first." [CORRECT]
C. "The physician ordered ambulation and you must comply."
D. "I will document your refusal and notify the physician."
Correct Answer: B
,Rationale: Correct because early postoperative ambulation prevents complications
including pneumonia, DVT, and ileus, and premedicating for pain facilitates
participation. This matches postoperative care standards.
Q3: On postoperative day 2, the client develops a temperature of 38.8°C, tachycardia,
and purulent drainage at the incision site. Which action should the nurse take first?
A. Apply a sterile dressing soaked in normal saline
B. Obtain wound cultures and notify the provider [CORRECT]
C. Administer acetaminophen 650 mg PO
D. Remove all sutures to allow drainage
Correct Answer: B
Rationale: Correct because purulent drainage with systemic signs indicates surgical site
infection requiring wound culture for pathogen identification and provider notification
for antibiotic therapy. Priority is assessment and communication.
Q4: Which preoperative instruction regarding NPO status is most accurate?
A. "You may drink clear liquids up to 1 hour before surgery."
B. "You should have nothing to eat or drink after midnight unless otherwise instructed."
[CORRECT]
C. "You may have a light breakfast the morning of surgery."
D. "Water is permitted up to 30 minutes before anesthesia."
Correct Answer: B
Rationale: Correct because standard NPO guidelines typically require nothing by mouth
after midnight to reduce aspiration risk, though specific institutional protocols may vary.
This matches preoperative fasting standards.
Q5: A client is scheduled for surgery and reports an allergy to latex. Which intervention
is most important?
A. Apply latex gloves during preoperative skin preparation
B. Ensure a latex-free environment and notify the surgical team [CORRECT]
C. Administer prophylactic corticosteroids
D. Postpone the surgery indefinitely
Correct Answer: B
,Rationale: Correct because latex allergy can cause severe anaphylaxis in the operating
room, requiring identification of latex-free supplies and communication with all team
members. Priority is allergen avoidance.
Q6: During the intraoperative phase, the nurse notes that the client is in the lithotomy
position. Which complication is the nurse most concerned about?
A. Brachial plexus injury
B. Peroneal nerve compression [CORRECT]
C. Pressure injury to the occiput
D. Respiratory compromise from abdominal compression
Correct Answer: B
Rationale: Correct because the lithotomy position places pressure on the lateral aspect
of the knees and lower legs, risking peroneal nerve injury and compartment syndrome.
This matches surgical positioning risks.
Q7: A postoperative client has not voided 8 hours after catheter removal. Which
intervention should the nurse implement first?
A. Insert an indwelling urinary catheter
B. Perform a bladder scan and assess for distention [CORRECT]
C. Administer bethanechol as prescribed
D. Increase oral fluid intake to 300 mL/hr
Correct Answer: B
Rationale: Correct because assessing bladder volume with a bladder scan determines if
urinary retention is present before invasive interventions are implemented. Priority is
assessment before action.
Q8: Which finding in a postoperative client requires immediate notification of the
surgeon?
A. Serous drainage on the surgical dressing 4 hours post-op
B. Blood pressure 92/58 mmHg with tachycardia 128 [CORRECT]
C. Pain rated 5/10 unrelieved by analgesic
D. Temperature 37.2°C
Correct Answer: B
, Rationale: Correct because hypotension and tachycardia in the postoperative period
indicate hemorrhage or hypovolemic shock requiring immediate surgical evaluation.
Priority is identifying hemodynamic instability.
Q9: A client is being prepared for discharge after abdominal surgery. Which statement
indicates understanding of wound care?
A. "I will remove the Steri-Strips after 3 days."
B. "I will keep the incision clean and dry and report redness or drainage." [CORRECT]
C. "I should soak the incision in the bathtub daily."
D. "I do not need a follow-up appointment if the wound looks good."
Correct Answer: B
Rationale: Correct because keeping the surgical incision clean and dry while monitoring
for signs of infection supports optimal healing and early detection of complications.
This matches discharge teaching.
Q10: The nurse is applying antiembolism stockings to a postoperative client. Which
action is correct?
A. Apply the stockings after the client has been sitting with legs dependent for 30
minutes
B. Measure the client's legs in the morning before rising and apply by turning the
stocking inside out [CORRECT]
C. Roll the stockings down to the ankles to check circulation
D. Apply powder to the legs before donning the stockings
Correct Answer: B
Rationale: Correct because measuring legs before rising prevents edema-related sizing
errors, and the inside-out application technique ensures even pressure distribution
without wrinkles. This matches antiembolism stocking application.
Q11: A client received general anesthesia. In the PACU, the nurse places the client in
which position?
A. Supine with head flat
B. Lateral recumbent position
C. High-Fowler's position
D. Supine with head elevated or side-lying [CORRECT]
Correct Answer: D
2024/2025 | Official Blueprint Replica |
Verified Q&A | Pass Guaranteed - A+
Graded
SECTION: Perioperative Nursing (12 Questions)
Unfolding Clinical Scenario: Postoperative Patient
A 68-year-old client underwent open cholecystectomy under general anesthesia and is
being transferred to the surgical unit.
Q1: During the preoperative assessment, the client reports taking warfarin 5 mg daily.
Which action should the nurse take first?
A. Document the medication and continue preop preparation
B. Notify the surgeon and anesthesia provider [CORRECT]
C. Instruct the client to take the dose the morning of surgery
D. Administer vitamin K prophylactically
Correct Answer: B
Rationale: Correct because warfarin increases bleeding risk during surgery and requires
coordination with the surgeon and anesthesia provider regarding discontinuation
timing. Priority is communication for patient safety.
Q2: On postoperative day 1, the client reports incisional pain rated 6/10 and refuses to
ambulate. Which response by the nurse is most appropriate?
A. "Ambulation will increase your pain and should be delayed."
B. "Early ambulation reduces complications and I will medicate you first." [CORRECT]
C. "The physician ordered ambulation and you must comply."
D. "I will document your refusal and notify the physician."
Correct Answer: B
,Rationale: Correct because early postoperative ambulation prevents complications
including pneumonia, DVT, and ileus, and premedicating for pain facilitates
participation. This matches postoperative care standards.
Q3: On postoperative day 2, the client develops a temperature of 38.8°C, tachycardia,
and purulent drainage at the incision site. Which action should the nurse take first?
A. Apply a sterile dressing soaked in normal saline
B. Obtain wound cultures and notify the provider [CORRECT]
C. Administer acetaminophen 650 mg PO
D. Remove all sutures to allow drainage
Correct Answer: B
Rationale: Correct because purulent drainage with systemic signs indicates surgical site
infection requiring wound culture for pathogen identification and provider notification
for antibiotic therapy. Priority is assessment and communication.
Q4: Which preoperative instruction regarding NPO status is most accurate?
A. "You may drink clear liquids up to 1 hour before surgery."
B. "You should have nothing to eat or drink after midnight unless otherwise instructed."
[CORRECT]
C. "You may have a light breakfast the morning of surgery."
D. "Water is permitted up to 30 minutes before anesthesia."
Correct Answer: B
Rationale: Correct because standard NPO guidelines typically require nothing by mouth
after midnight to reduce aspiration risk, though specific institutional protocols may vary.
This matches preoperative fasting standards.
Q5: A client is scheduled for surgery and reports an allergy to latex. Which intervention
is most important?
A. Apply latex gloves during preoperative skin preparation
B. Ensure a latex-free environment and notify the surgical team [CORRECT]
C. Administer prophylactic corticosteroids
D. Postpone the surgery indefinitely
Correct Answer: B
,Rationale: Correct because latex allergy can cause severe anaphylaxis in the operating
room, requiring identification of latex-free supplies and communication with all team
members. Priority is allergen avoidance.
Q6: During the intraoperative phase, the nurse notes that the client is in the lithotomy
position. Which complication is the nurse most concerned about?
A. Brachial plexus injury
B. Peroneal nerve compression [CORRECT]
C. Pressure injury to the occiput
D. Respiratory compromise from abdominal compression
Correct Answer: B
Rationale: Correct because the lithotomy position places pressure on the lateral aspect
of the knees and lower legs, risking peroneal nerve injury and compartment syndrome.
This matches surgical positioning risks.
Q7: A postoperative client has not voided 8 hours after catheter removal. Which
intervention should the nurse implement first?
A. Insert an indwelling urinary catheter
B. Perform a bladder scan and assess for distention [CORRECT]
C. Administer bethanechol as prescribed
D. Increase oral fluid intake to 300 mL/hr
Correct Answer: B
Rationale: Correct because assessing bladder volume with a bladder scan determines if
urinary retention is present before invasive interventions are implemented. Priority is
assessment before action.
Q8: Which finding in a postoperative client requires immediate notification of the
surgeon?
A. Serous drainage on the surgical dressing 4 hours post-op
B. Blood pressure 92/58 mmHg with tachycardia 128 [CORRECT]
C. Pain rated 5/10 unrelieved by analgesic
D. Temperature 37.2°C
Correct Answer: B
, Rationale: Correct because hypotension and tachycardia in the postoperative period
indicate hemorrhage or hypovolemic shock requiring immediate surgical evaluation.
Priority is identifying hemodynamic instability.
Q9: A client is being prepared for discharge after abdominal surgery. Which statement
indicates understanding of wound care?
A. "I will remove the Steri-Strips after 3 days."
B. "I will keep the incision clean and dry and report redness or drainage." [CORRECT]
C. "I should soak the incision in the bathtub daily."
D. "I do not need a follow-up appointment if the wound looks good."
Correct Answer: B
Rationale: Correct because keeping the surgical incision clean and dry while monitoring
for signs of infection supports optimal healing and early detection of complications.
This matches discharge teaching.
Q10: The nurse is applying antiembolism stockings to a postoperative client. Which
action is correct?
A. Apply the stockings after the client has been sitting with legs dependent for 30
minutes
B. Measure the client's legs in the morning before rising and apply by turning the
stocking inside out [CORRECT]
C. Roll the stockings down to the ankles to check circulation
D. Apply powder to the legs before donning the stockings
Correct Answer: B
Rationale: Correct because measuring legs before rising prevents edema-related sizing
errors, and the inside-out application technique ensures even pressure distribution
without wrinkles. This matches antiembolism stocking application.
Q11: A client received general anesthesia. In the PACU, the nurse places the client in
which position?
A. Supine with head flat
B. Lateral recumbent position
C. High-Fowler's position
D. Supine with head elevated or side-lying [CORRECT]
Correct Answer: D
