WorksheetsEXAM 4
Total questions: 63
Worksheet time: 32mins
A nurse is caring for a post-op patient who suddenly becomes restless, reports severe thirst, and has a heart rate of 160 bpm with a blood pressure of 88/60 mm Hg. Which of the following actions should the nurse take first?
A. Reassure the patient and offer ice chips
B. Notify the provider
C. Assess the surgical site and check for bleeding
D. Administer IV fluids
A post-op patient is receiving IV morphine. The nurse notes the respiratory rate has decreased to 10 breaths per minute. What should the nurse do first?
A. Administer oxygen
B. Stop the IV morphine
C. Notify the provider
D. Prepare to administer naloxone
A
B
C
D
During surgery, a patient develops a rigid jaw, dark urine, temperature of 104°F, and hypotension. Which of the following is the priority action?
A. Lower the room temperature
B. Prepare for dantrolene administration
C. Notify the surgeon and anesthesiologist
D. Increase IV fluid rate
A
B
C
D
Which of the following is the nurse’s priority when caring for a patient receiving continuous bladder irrigation (CBI) after TURP?
A. Irrigate the catheter every hour
B. Monitor for bladder spasms
C. Ensure the output equals or exceeds input
D. Encourage oral fluids
A
B
C
D
The patient in PACU becomes dyspneic, cyanotic, and reports chest pain with a heart rate of 132 bpm. What should the nurse suspect?
A. Wound dehiscence
B. Pulmonary embolism
C. Atelectasis
D. Respiratory acidosis
A
B
C
D
A nurse is preparing to obtain a wound culture. Which of the following is correct?
A. Swab the drainage directly
B. Clean the wound after swabbing
C. Clean the wound before swabbing
D. Use sterile gloves for the procedure
A
B
C
D
A client’s surgical incision bursts open, and tissue protrudes. What is the nurse’s priority action?
A. Apply sterile dry gauze
B. Push tissue back in gently
C. Cover with sterile moist saline gauze
D. Notify the charge nurse later
A
B
C
D
A client with acute pancreatitis is placed on NPO status and started on TPN. What is the primary goal of this intervention?
A. Prevent aspiration during feeding
B. Improve appetite and nutrient intake
C. Allow the GI tract to rest and provide nutrition
D. Prepare for immediate surgical intervention
A
B
C
D
A nurse is planning to resume oral intake for a client post-gastric bypass surgery. What is the first intervention?
A. Administer a full meal
B. Offer ice chips only
C. Provide clear liquids in small amounts
D. Assess gag reflex
A
B
C
D
A nurse is preparing a client for discharge after surgery. What is the most important nursing action?
A. Notify the family
B. Provide verbal instructions only
C. Confirm patient understanding through return demonstration
D. Ask the client if they feel ready to leave
A
B
C
D
A patient admits to drinking water 1 hour before surgery. What is the nurse’s priority action?
A. Cancel the surgery
B. Inform the surgeon immediately
C. Document and monitor
D. Delay the procedure 30 minutes
A
B
C
D
Which item must be removed or managed before surgery?
A. Glasses
B. Dentures
C. Jewelry
D. All of the above
A
B
C
D
What should the nurse do with a wedding ring a patient refuses to remove before surgery?
A. Forcefully remove it
B. Leave it as is
C. Tape it securely with paper tape
D. Cut it off in the OR
A
B
C
D
A nurse confirms the surgical site with the patient and marks it before transferring to the OR. What safety measure is this?
A. Pre-op briefing
B. Time-out procedure
C. Consent verification
D. Sterility check
A
B
C
D
What is the purpose of a surgical time-out?
A. Confirm sterile technique
B. Ensure anesthesia is ready
C. Final verification of procedure, site, and patient
D. Prepare tools for surgery
A
B
C
D
During surgery, the circulating nurse notices a team member contaminate the sterile field. What is their priority action?
A. Tell the surgeon afterward
B. Continue the surgery
C. Stop the individual and break the field
D. Replace the scrub tech
A
B
C
D
The scrub nurse is responsible for which of the following?
A. Administering anesthesia
B. Monitoring blood loss
C. Counting sponges and instruments
D. Managing post-op recovery
A
B
C
D
A nurse administers morphine to a post-op client. What is the primary purpose of this medication?
A. Reduce blood pressure
B. Prevent infection
C. Treat pain and anxiety
D. Lower fever
A
B
C
D
A post-op client receiving morphine IV has a respiratory rate of 8 breaths/min. What should the nurse do first?
A. Notify the provider
B. Administer oxygen
C. Stop the IV infusion
D. Elevate the head of the bed
A
B
C
D
What is the antidote for morphine overdose?
A. Atropine
B. Naloxone
C. Flumazenil
D. Protamine sulfate
A
B
C
D
A nurse administers naloxone to a client with respiratory depression. What is the priority action after administration?
A. Start IV fluids
B. Monitor blood sugar
C. Monitor airway, breathing, and vital signs
D. Discharge the client
A
B
C
D
What emergency supplies should the nurse have ready when administering opioids?
A. Glucometer
B. Cardiac monitor
C. Code cart, suction, and intubation tray
D. Antibiotics
A
B
C
D
A nurse administers lorazepam before a procedure. What is the priority assessment?
A. Bowel sounds
B. Skin turgor
C. Level of sedation
D. Nutritional status
A
B
C
D
A client is prescribed steroids for an inflammatory condition. What discharge instruction is most important?
A. Take with food
B. Increase potassium
C. Taper the dose slowly
D. Monitor blood pressure
A
B
C
D
A nurse prepares to apply a new fentanyl patch. What is a key safety step?
A. Rub the site with alcohol
B. Shave the skin
C. Document date, time, and location
D. Apply over open wound
A
B
C
D
What must the nurse do before applying a new transdermal medication patch?
A. Administer oral pain medication
B. Check for the previous patch on the body
C. Soak the area in warm water
D. Apply lotion to the site
A
B
C
D
After placing a transdermal patch, the nurse initials and dates it. What is the purpose of this action?
A. To confirm the dose was accurate
B. To allow the patient to track pain
C. To monitor effectiveness
D. To ensure clear record of application time and site
A
B
C
D
A post-op client is experiencing thick secretions and diminished breath sounds. Which nursing intervention should be implemented first?
A. Encourage fluid intake
B. Administer pain medication
C. Assist to High Fowler’s position
D. Provide warm compress to chest
A
B
C
D
Which intervention best supports effective airway clearance in a post-op patient?
A. Encourage bed rest
B. Provide only oxygen
C. Turn, cough, and deep breathe (TCDB)
D. Limit fluid intake
A
B
C
D
A nurse teaches a client to use an incentive spirometer. Which statement indicates understanding?
A. “I should exhale forcefully into the device.”
B. “I’ll hold my breath for 3–5 seconds after inhaling.”
C. “I’ll blow quickly into it every 4 hours.”
D. “I use this only before meals.”
A
B
C
D
Which finding indicates that airway clearance interventions have been effective?
A. Coarse crackles
B. Elevated heart rate
C. Clear breath sounds and O2 sat of 98%
D. Low urine output
A
B
C
D
Which device helps prevent atelectasis in post-op clients?
A. TENS unit
B. Incentive spirometer
C. Anti-embolism stockings
D. Abdominal binder
A
B
C
D
A nurse is caring for a client after abdominal surgery. Which intervention helps prevent respiratory complications?
A. Limit fluid intake
B. Offer a high-fat diet
C. Ambulate early and often
D. Restrict movement
A
B
C
D
What is the most reliable indicator of respiratory improvement in a post-op client?
A. Decreased appetite
B. Clear breath sounds and normal RR
C. Reduced pain level
D. Presence of wound drainage
A
B
C
D
A nurse suspects malignant hyperthermia in a client during surgery. Which symptom supports this concern?
A. BP 140/90, HR 80, warm skin
B. Temp 102°F, jaw rigidity, dark-colored urine
C. Sweating, low-grade fever, muscle spasms
D. Pulse 100, oxygen saturation 94%, tremors
A
B
C
D
What is the nurse’s first action if malignant hyperthermia is suspected?
A. Lower the OR temperature
B. Start chest compressions
C. Call the provider and the RN immediately
D. Increase IV fluid rate
A
B
C
D
A nurse notes chest pain, cyanosis, and tachycardia in a post-op client. What complication is most likely?
A. Pneumonia
B. Atelectasis
C. Pulmonary embolism
D. Internal bleeding
A
B
C
D
A nurse is monitoring a post-op patient with sudden hypotension (BP 88/60), HR 144, and restlessness. Which complication is most likely?
A. Fluid overload
B. Internal bleeding / hypovolemic shock
C. Pulmonary embolism
D. Urinary retention
A
B
C
D
Which sign is a priority red flag for internal bleeding after surgery?
A. Mild abdominal pain
B. Thirst and low urine output
C. Sudden drop in BP and increasing HR
D. Slight wound drainage
A
B
C
D
Which client behavior would most concern the nurse in a post-op setting?
A. Slight pain at incision site
B. Asking for ice chips
C. Refusing to ambulate
D. Appearing restless and repeatedly shifting in bed
A
B
C
D
A nurse is preparing to start oral nutrition for a client recovering from pancreatitis. Which action should the nurse take first?
A. Offer a full meal with high-protein content
B. Start the client on clear liquids
C. Check for the return of bowel sounds
D. Assess the swallow reflex
A
B
C
D
A nurse is providing discharge teaching to a surgical patient. What is the most important responsibility of the nurse?
A. Have the client sign the instructions
B. Schedule a follow-up appointment
C. Provide written instructions only
D. Ensure that the client understands the instructions
A
B
C
D
During preoperative preparation, the nurse finds that the client ate a small breakfast. What should the nurse do?
A. Proceed as scheduled
B. Document the finding and continue
C. Notify the provider immediately
D. Instruct the client to drink water to dilute contents
A
B
C
D
A client receiving IV morphine has a respiratory rate of 8 breaths/min. What is the nurse’s priority action?
A. Decrease the infusion rate
B. Notify the healthcare provider
C. Administer oxygen and monitor
D. Stop the infusion and prepare to give naloxone
A
B
C
D
A nurse is preparing to discharge a client who has been taking corticosteroids. Which instruction is most important to include?
A. “Discontinue the medication 24 hours before discharge.”
B. “Taper the medication gradually before stopping.”
C. “Double the dose if you miss one.”
D. “Take the steroid only with antacids.”
A
B
C
D
A nurse is applying a new fentanyl patch. Which of the following steps should be taken? (Select all that apply.)
A. Document the date and time of application
B. Apply to the inner thigh for fast absorption
C. Remove any old patches before applying a new one
D. Initial and date the new patch
A
B
C
D
A post-op client is experiencing ineffective airway clearance. Which of the following actions should the nurse implement first?
A. Encourage intake of warm fluids
B. Place the client in High Fowler’s position
C. Administer antitussive medication
D. Apply a warm compress to the chest
A
B
C
D
A nurse is educating a patient about using an incentive spirometer. What instruction should the nurse include?
A. “Exhale slowly into the mouthpiece.”
B. “Hold your breath for 3–5 seconds after inhaling.”
C. “Use only when experiencing shortness of breath.”
D. “Use after meals to improve digestion.”
A
B
C
D
A post-op client develops jaw rigidity, dark urine, and a pulse of 58. What is the nurse’s first action?
A. Administer IV fluids
B. Call the MD and RN immediately
C. Apply a warm blanket
D. Place the client in a side-lying position
A
B
C
D
A nurse is caring for a client 6 hours post-op who suddenly reports chest pain and shortness of breath. Which of the following is the priority action?
A. Notify the rapid response team
B. Place the client in Trendelenburg
C. Administer morphine
D. Encourage coughing
A
B
C
D
A client post-op has a BP drop from 132/90 to 89/68 and a pulse increase from 68 to 160. The client is restless and states, “I feel like something bad is happening.” What should the nurse do next?
A. Recheck vitals in 30 minutes
B. Offer reassurance and stay with the client
C. Call the provider and assess for internal bleeding
D. Administer anti-anxiety medication
A
B
C
D
Which of the following is the appropriate technique when caring for a post-op wound dressing?
A. Use sterile gloves for changing all dressings
B. Use clean gloves unless applying a sterile dressing
C. Wash hands only if the wound appears infected
D. Sterile technique is not necessary if the wound is dry
A
B
C
D
When assessing a surgical wound, what is the nurse’s priority assessment?
A. Measuring circumference of surrounding tissue only
B. Noting color, size, drainage, and signs of infection
C. Only observing drainage color
D. Waiting until drainage increases to notify the provider
A
B
C
D
A nurse observes evisceration in a post-op client. What is the immediate nursing action?
A. Apply dry sterile gauze and notify the RN
B. Cover the protruding tissue with moist sterile gauze and notify the RN immediately
C. Attempt to push the tissue back in
D. Place the client in Trendelenburg position and ambulate
A
B
C
D
While monitoring a client with continuous bladder irrigation (CBI) after a TURP, the nurse notices reduced output and clots. What is the priority nursing action?
A. Increase the irrigation flow rate
B. Notify the healthcare provider immediately
C. Clamp the catheter for 30 minutes
D. Document findings and continue monitoring
A
B
C
D
A post-op client receiving opioids shows signs of respiratory depression with a RR of 8 breaths per minute. What is the nurse’s first action?
A. Administer naloxone (Narcan) immediately
B. Call the healthcare provider and wait for orders
C. Stop the opioid infusion and prepare to administer naloxone
D. Encourage the client to take deep breaths
A
B
C
D
What is the primary purpose of anti-embolism stockings postoperatively?
A. To relieve pain
B. To prevent deep vein thrombosis (DVT)
C. To reduce edema by restricting blood flow
D. To increase arterial circulation
A
B
C
D
When applying a TENS unit for post-op pain management, what should the nurse ensure?
A. Apply directly over broken skin
B. Clip hair if necessary and apply to clean, hair-free skin
C. Place electrodes over the surgical incision
D. Leave the device on continuously for 24 hours
A
B
C
D
Phantom limb pain after amputation is caused by:
A. Psychological stress from loss of limb
B. Brain signals misinterpreting nerve activity from the missing limb
C. Infection at the amputation site
D. Poor circulation to the residual limb
A
B
C
D
Which of the following is an example of complementary or alternative medicine (CAM) for post-op pain?
A. Opioid analgesics
B. Acupuncture and warm/cold therapy
C. Steroid medications
D. Antibiotics
A
B
C
D
A client with acute polycystic kidney disease complains of shoulder pain. What should the nurse consider as a cause?
A. Shoulder joint arthritis
B. Referred pain from kidney inflammation
C. Rotator cuff injury
D. Muscle strain from surgery
A
B
C
D
In an emergency situation, what is the nurse’s first priority assessment?
A. Blood pressure
B. Airway patency
C. Pain level
D. Pulse oximetry
A
B
C
D
A patient is scheduled for surgery and is to hold antibiotics and antiemetics beforehand. What is the nurse’s best action?
A. Administer the medications as scheduled
B. Follow the doctor’s orders and withhold the medications before surgery
C. Give half the dose to avoid side effects
D. Call the pharmacy to clarify the orders
A
B
C
D
