Ignatavicius: Medical-Surgical Nursing, 10th Edition
Chapter 09: Concepts of Care for Perioperative Patients
Answer Key – NCLEX Examination Challenges, Clinical Judgment Challenges, and
Mastery Questions
Answer Key – NCLEX Examination Challenges
NCLEX Examination Challenge 9-1
Physiological Integrity: Pharmacological and Parenteral Therapies
The surgery for a client scheduled for an 8:00 AM procedure is delayed until 11:00 AM. What is
the appropriate nursing action regarding administration of preoperative prophylactic antibiotic?
A. Administer at 8:00 AM as originally prescribed.
B. Request an order for the administration time to be changed to 10:00 AM.
C. Do not administer, as preoperative prophylactic antibiotics are optional.
D. Hold the antibiotic until immediately following surgery, and then administer.
Correct Answer: B
Rationale: According to the Surgical Care Improvement Project (SCIP) guidelines,
prophylactic antibiotics should be given within one hour before the surgical incision.
Cognitive Level: Application
Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
Nursing Process Step: Implementation
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NCLEX Examination Challenge 9-2
Physiological Integrity: Reduction of Risk Potential
The nurse is caring for a client who is to undergo surgery at 6:00 AM today. Which assessment
data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all
that apply.
A. Blood pressure 130/72
B. Serum potassium 3.5 mEq/L
C. Diffuse rash on upper torso*
D. Took 650 mg of aspirin yesterday*
E.
Has not had food nor water since 9:00 PM last night
Correct Answers: C, D
Rationale: A diffuse rash could be an indication of a health deviation that must be assessed
before surgery. Taking aspirin (or any other medication that anti-coagulates) is generally
not permitted for a certain period of time before surgery. Therefore, the nurse will notify
the surgeon and anesthesia provide of both of these assessment findings. A blood
pressure of 130/72 and a serum potassium of 3.5 mEq/L are normal findings, as is the
adherence of the client who has not had food nor water for the recommended time before
surgery.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Nursing Process Step: Assessment
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NCLEX Examination Challenge 9-3
Physiological Integrity: Reduction of Risk Potential
The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse
include? Select all that apply.
A. Begin practicing leg exercises prior to surgery.*
B. Repeat leg exercises several times daily for each leg.*
C. Push the ball of the foot into the bed until the calf and thigh muscles contract.*
D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon.*
E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.*
Correct Answers: A, B, C, D, E
Rationale: Teaching regarding postoperative leg exercises should include having the client
begin practicing the exercises before surgery; repeating the exercises several times daily
for each leg; pushing the ball of the foot into the bed until the calf and thigh muscles
contract; discontinuing exercises and contacting the surgeon if pain of warmth in the calf
is present; and pointing toes of one foot towards the bottom of the bed, then towards the
face, and switching.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Nursing Process Step: Implementation
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NCLEX Examination Challenge 9-4
Physiological Integrity: Reduction of Risk Potential
The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which
client statement will the nurse respond to as the priority?
A.
“When I eat shrimp, my tongue swells and I have trouble breathing.” *
B. “I'm feeling more anxious about my surgery than I thought I would be.”
C. “I’m not sure what I will do if insurance doesn’t cover this expensive hip replacement.”
D.
“My sister had anesthesia a few months ago and she said she did not like the way she felt.”
Correct Answer: A
Rationale: Clients have often heard historically that an allergy to iodine or shellfish indicates a
risk for a reaction to the agents used to clean the surgical area. Shellfish allergies are
usually associated with a reaction to tropomyosin - not iodine. Still, the nurse will
respond to this statement as the priority to ascertain whether the reported reaction is
only to shellfish consumption, or if there has ever been a similar reaction when exposed
to other substances, and then provide teaching as needed. All other client statements can
then be addressed.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Nursing Process Step: Implementation
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NCLEX Examination Challenge 9-5
Physiological Integrity: Reduction of Risk Potential
The nurse is caring for a client who has been readmitted to the medical-surgical unit following
surgery for a hernia repair completed under general anesthesia. What is the priority nursing
assessment?
A.
Perform thorough auscultation of the lungs
B.
Assess response to pin-prick stimulation from feet to mid-chest level
C.
Determine level of consciousness and response to environmental stimuli*
D.
Compare blood pressure findings from preoperative assessment to the present
Correct Answer: C
Rationale: After general anesthesia, which affects the entire body, the priority assessment is to
determine that the client’s level of consciousness has returned. All other assessment can
be performed subsequently, including lung auscultation, as there is no indication that the
client is experiencing any type of respiratory distress.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Nursing Process Step: Implementation
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NCLEX Examination Challenge 9-6
Physiological Integrity: Reduction of Risk Potential
In the early postoperative period, which assessment finding in a client who had an epidural
during surgery requires immediate nursing intervention?
A.
Blood pressure of 142/90
B.
Headache of 4 on a 1-10 scale
C.
Gradual return of motor function
D.
Increase in back pain when coughing*
Correct Answer: D
Rationale: An increase in back pain can be indicative of an epidural hematoma; therefore, the
nurse will immediately address this finding. Blood pressure can be compared to baseline
after addressing the back pain, as can the headache. The nurse can continue to monitor
the expected, gradual return of motor function.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Nursing Process Step: Assessment
NCLEX Examination Challenge 9-7
Psychosocial Integrity
The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain
medication after surgery. What is the appropriate nursing response? Select all that apply.
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A.
“Why do you think you're going to get hooked?”
B.
“Don't worry, I won't give you any opioid medications.”
C.
“Have you had concerns with drug dependence in the past?”*
D.
“Tell me what makes you most fearful about taking opioid medication.”*
E.
“There are proper ways of taking opioids so you will not become dependent.”*
Correct Answers: C, D, E
Rationale: The nurse will use therapeutic communication to determine the client’s underlying
concerns. This is accomplished by asking the client if there has been a past history of
drug dependence (which may explain the reluctance), what seems most fearful about
taking opioids (which gives the nurse the chance to dispel myths), and teaching that there
are proper ways of taking opioids (as directed and for a short period of time) that is
meant to keep the client from becoming dependent. Asking “why” is nontherapeutic and
can shut down the line of communication between the client and nurse, as this approach
demands a response. The nurse will not promise to avoid give the patient opioids at this
time, as further investigation of the client’s concerns are warranted first.
Cognitive Level: Analysis
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
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Answer Key – Clinical Judgment Challenge
Clinical Judgment Challenge 9-1
Patient-Centered Care
A 60-year old client with a history of opioid misuse fell a week ago, and did not seek care until
two days ago when a grandchild found him lying in the kitchen of his residence. He was then
brought and admitted to the hospital. Having just had hip replacement surgery, he is now
readmitted to the medical-surgical unit from the PACU. He is responsive when asked his name
yet is mildly confused about where he is. He is pulling at his oxygen cannula but does allow it to
be replaced into his nostrils. Initial vital signs upon return to the medical-surgical unit included
BP 140/90, pulse 100, respirations 22. Vital signs taken 15 minutes later show BP 142/92, pulse
100, respirations 22. He says he hurts “really badly” and wants to know when he will receive
pain medication.
1. What assessment information in this client situation is the most important and immediate
concern for the nurse? (Hint: Identify the relevant information first to determine what is
most important.)
It is relevant to note that the client has a history of opioid misuse, and that his behaviors
(pulling at the cannula and questioning when he will receive pain medication) are
indicative of pain. His vital signs, including an elevated blood pressure, pulse on the high
end of normal, and increased respirations, have not changed dramatically between the
first and second assessment, which indicates that the problem is still present.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information
presented in this situation.)
Pain, or delirium, are two client conditions that could be consistent with the most
relevant information. It is important to note, however, that the client is able to respond to
his name, and to form a coherent thought about pain medication.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities
and determine their urgency and risk for this client.)
The client is most likely experiencing pain. Having a history of opioid misuse, he may not
respond to the normal amount of pain medication administered after surgery; he may
need a higher dose.
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4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired
outcomes first to decide which interventions are appropriate and those that should be
avoided.)
It is most likely that administration of pain medication in a dose that truly addressed the
client’s pain will achieve the desired outcome. Ignoring the client’s concern could be
potentially harmful, as pain will continue to increase, and the client’s restlessness will
rise in proportion. This can affect the healing process.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching,
documentation, requested health care provider orders or prescriptions, nursing skills,
collaboration with or referral to health team members, etc.)
An assessment should be completed. Vital signs should be compared against the client’s
presurgical baseline. Attention should be given to whether the patient has a fever (which
may indicate delirium). In the absence of other findings, the nurse should determine when
the next pain medication is due, and what dose has been prescribed. If needed, the nurse
should then collaborate with the surgeon to determine if the appropriate dose has been
prescribed, given the patient’s presentation and history.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client
condition.)
Signs that indicate an improvement in condition include client relaxation, and subjective
report of lessened pain. Vital signs should return to normal, or in keeping with the
presurgical baseline.
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Answer Key – Mastery Question
NCLEX Mastery Question #1
Physiological Integrity: Reduction of Risk Potential
The nurse is completing a preoperative physical assessment for a client who will have surgery
this afternoon. Which assessment finding will the nurse report to the operative team? Select all
that apply.
A.
B.
C.
D.
E.
F.
Left arm prosthesis*
Skin turgor < 3 seconds
Blood pressure 160/100*
Presence of chest rigidity*
Has been NPO since midnight
Expressed concern about surgery payment
Correct Answers: A, C, D
Rationale: The nurse will report assessment findings of a left arm prosthesis (as this must be
addressed prior to surgery); blood pressure of 160/100 (as this is high, which may delay
surgery); and the presence of chest rigidity (which is an abnormal finding that may
indicate respiratory compromise which could affect whether surgery takes place) to the
operative team. The findings of skin turgor of < 3 seconds, adherence to the NPO plan,
and a natural concern about payment for surgery do not require reporting to the
operative team.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Nursing Process Step: Implementation
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NCLEX Mastery Question #2
Physiological Integrity: Reduction of Risk Potential
The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it
is due. What is the priority nursing response?
A.
“You cannot have more pain medicine until an hour from now.”
B.
“Can you describe the pain you are having, and rate it on a 1-10 scale?”*
C.
“I can help you begin a pain diary so we can see trends when your pain worsens.”
D. “Let’s try some relaxation exercises to help address the discomfort you are feeling.”
Correct Answer: B
Rationale: The nurse will assess the client’s level of pain to determine whether it is increasing,
unmanaged, or able to be managed until the next dose of medication is due. Telling the
client they cannot have medication for another hour, without conducting an assessment,
is inappropriate, as cues to a changing health status could be missed. Starting a pain
diary may be an appropriate intervention at a later time, but does not address the client’s
immediate concern. Providing relaxation exercises may be appropriate, but only after an
assessment is conducted to determine the cause of the client’s pain.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Nursing Process Step: Implementation
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