Question

A nurse is caring for a postoperative patient who reports acute incisional pain rated 8 out of 10. Which of the following is the priority nursing intervention?

Answer 1

Correct Answers:

Administer prescribed opioid analgesic

Rationale :

💎 Pain rated 8/10 indicates severe acute pain that requires immediate pharmacologic intervention for effective relief.

💎 Administering a prescribed opioid helps reduce the patient’s pain level quickly, improving comfort and facilitating healing.

💎 Untreated severe pain can trigger sympathetic responses such as tachycardia, hypertension, and increased oxygen demand.

💎 This action aligns with the ABC (Airway, Breathing, Circulation) and comfort hierarchy — addressing pain enhances recovery.

💎 Once the medication is effective, nonpharmacologic methods like positioning and relaxation may be added for synergy.

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Answer 2

Correct Answers:

Monitor the patient's respiratory rate and sedation level every 1 - 2 hours

Rationale :

🔶 Morphine, an opioid in PCA pumps, can cause respiratory depression and sedation if overdosed or accumulated.

🔶 Frequent monitoring ensures early detection of hypoventilation or excessive sedation, preventing respiratory arrest.

🔶 The nurse must assess rate, depth, and quality of respirations, along with level of consciousness.

🔶 Documentation of these assessments helps ensure safe and effective pain management in PCA use.

🔶 This aligns with safety and monitoring principles under the National Patient Safety Goals.

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Answer 3

Correct Answers:

Ensuring that informed consent has been signed and is in the medical record

Rationale :

✴ Informed consent is a legal and ethical requirement prior to any surgical procedure.

✴ The nurse verifies that the patient understands the procedure, risks, and alternatives before signing.

✴ The surgeon obtains consent, but the nurse ensures it is documented and present before surgery.

✴ Surgery cannot proceed legally without a signed consent form in the chart.

✴ This step protects both the patient’s autonomy and the healthcare provider legally and ethically.

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Answer 4

Correct Answers:

Instruct the patient on the use of an incentive spirometer

Rationale :

🟢 The incentive spirometer promotes lung expansion, preventing postoperative complications such as atelectasis and pneumonia.

🟢 Teaching this preoperatively ensures the patient is familiar with technique when recovering from anesthesia.

🟢 Deep breathing improves oxygenation and alveolar ventilation after surgery.

🟢 Encouraging its use reduces respiratory distress and improves outcomes, especially in abdominal surgeries.

🟢 It is part of postoperative pulmonary hygiene teaching for all surgical patients.

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Answer 5

Correct Answers:

Redness, warmth, purulent drainage and fever of 101.8 degree F (38.8 degree C)

Rationale :

♦ These findings are classic indicators of wound infection, showing inflammatory and systemic immune response.

♦ Redness and warmth suggest localized inflammation around the incision.

♦ Purulent drainage confirms the presence of pathogens and tissue breakdown.

♦ Fever reflects systemic infection and requires prompt medical intervention.

♦ Early recognition and reporting prevent sepsis and delayed wound healing.

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Answer 6

Correct Answers:

Improving surgical site identification and time-out procedures

Rationale :

🔷 The National Patient Safety Goals (NPSGs) emphasize correct patient, procedure, and site identification.

🔷 A time-out is performed before surgery to confirm all identifiers and prevent wrong-site or wrong-patient surgery.

🔷 This safety measure minimizes preventable surgical errors and promotes team communication.

🔷 It supports Joint Commission standards for surgical safety.

🔷 Enhancing these protocols protects patient well-being and institutional reputation.

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Answer 7

Correct Answers:

The client now has a fever of 100.4 degree
Patient is complaining of chest pain now

Rationale :

💠 Fever indicates a potential infection, and surgery should be delayed until it’s evaluated.

💠 Chest pain suggests possible cardiac ischemia or respiratory complication that must be assessed before anesthesia.

💠 Reporting these findings prevents perioperative cardiac or respiratory emergencies.

💠 Vital signs (BP 120/80 and HR 76) are normal and not urgent findings.

💠 Preoperative reporting ensures safe surgical clearance and risk management.

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Answer 8

Correct Answers:

Empty and compress the drain bulb when it is half full or every 8 hours, using sterile technique

Rationale :

🟣 Proper emptying maintains negative pressure, allowing continuous drainage of fluids.

🟣 Using sterile technique prevents introduction of infection at the drain site.

🟣 Regular monitoring prevents blockage and backflow of drainage.

🟣 Compressing the bulb restores suction pressure for effective drainage.

🟣 This promotes healing and prevents fluid accumulation (seroma or hematoma).

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Answer 9

Correct Answers:

Monitoring for signs of hemorrhage

Rationale :

🔴 The first postoperative hour is the critical phase where internal or external bleeding is most likely to occur.

🔴 Signs include tachycardia, hypotension, pallor, and decreased urine output.

🔴 Early detection prevents hypovolemic shock and life-threatening complications.

🔴 Monitoring involves checking dressing saturation, drain output, and vital trends.

🔴 Pain assessment and bowel checks follow once bleeding is ruled out.

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Answer 10

Correct Answers:

Immediately assess the surgical site for signs of wound dehiscence or evisceration

Rationale :

⚫ A “popping” sound with sudden pain after coughing suggests possible dehiscence or evisceration.

⚫ The nurse must inspect the wound immediately for visible separation or protrusion of organs.

⚫ This is a surgical emergency requiring sterile dressing application and physician notification.

⚫ Early recognition prevents infection and shock.

⚫ Pain medication or further coughing may worsen the separation; assessment is priority.

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NUR 105 Eve A Exam 1

No.

1 :
A nurse is caring for a postoperative patient who reports acute incisional pain rated 8 out of 10. Which of the following is the priority nursing intervention?

2 :
A nurse is caring for a postoperative patient who is using a patient-controlled analgesia (PCA) [ump with morphine. Which of the following nursing interventions is the most appropriate to ensure safe and effective pain management?

3 :
A nurse is caring for a client who is scheduled for surgery in the morning. Which of the following is the most important preoperative priority for the nurse?

4 :
A 56-year old patient is scheduled for a laparoscopic cholecystectomy surgery in the morning. During preoperative period teaching, which of the following should the nurse include:

5 :
A nurse is assessing a patient on postoperative day 3 after abdominal surgery. Which of the following findings is most indicative off wound infection?

6 :
What are the key focus areas of the National Patient Safety Goals for surgery?

7 :
The nurse is planning care for a patient who is having surgery at 9 am today. Which of the following assessment data would you report to the Health Care Provider? Select all that apply.

8 :
A postoperative patient has a Jackson-Pratt (JP) drain in place. Which of the follow nursing interventions is most appropriate for ensuring proper function and preventing complications of the JP drain?

9 :
A nurse is caring for a patient in the immediate post-operative period following abdominal surgery. Which of the following assessments is the highest priority during the first hour post-op?

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NUR 105 Eve A Exam 1

No.

1 : A nurse is caring for a postoperative patient who reports acute incisional pain rated 8 out of 10. Which of the following is the priority nursing intervention?

2 : A nurse is caring for a postoperative patient who is using a patient-controlled analgesia (PCA) [ump with morphine. Which of the following nursing interventions is the most appropriate to ensure safe and effective pain management?

3 : A nurse is caring for a client who is scheduled for surgery in the morning. Which of the following is the most important preoperative priority for the nurse?

4 : A 56-year old patient is scheduled for a laparoscopic cholecystectomy surgery in the morning. During preoperative period teaching, which of the following should the nurse include:

5 : A nurse is assessing a patient on postoperative day 3 after abdominal surgery. Which of the following findings is most indicative off wound infection?

6 : What are the key focus areas of the National Patient Safety Goals for surgery?

7 : The nurse is planning care for a patient who is having surgery at 9 am today. Which of the following assessment data would you report to the Health Care Provider? Select all that apply.

8 : A postoperative patient has a Jackson-Pratt (JP) drain in place. Which of the follow nursing interventions is most appropriate for ensuring proper function and preventing complications of the JP drain?

9 : A nurse is caring for a patient in the immediate post-operative period following abdominal surgery. Which of the following assessments is the highest priority during the first hour post-op?

1 :
A nurse is caring for a postoperative patient who reports acute incisional pain rated 8 out of 10. Which of the following is the priority nursing intervention?

2 :
A nurse is caring for a postoperative patient who is using a patient-controlled analgesia (PCA) [ump with morphine. Which of the following nursing interventions is the most appropriate to ensure safe and effective pain management?

3 :
A nurse is caring for a client who is scheduled for surgery in the morning. Which of the following is the most important preoperative priority for the nurse?

4 :
A 56-year old patient is scheduled for a laparoscopic cholecystectomy surgery in the morning. During preoperative period teaching, which of the following should the nurse include:

5 :
A nurse is assessing a patient on postoperative day 3 after abdominal surgery. Which of the following findings is most indicative off wound infection?

6 :
What are the key focus areas of the National Patient Safety Goals for surgery?

7 :
The nurse is planning care for a patient who is having surgery at 9 am today. Which of the following assessment data would you report to the Health Care Provider? Select all that apply.

8 :
A postoperative patient has a Jackson-Pratt (JP) drain in place. Which of the follow nursing interventions is most appropriate for ensuring proper function and preventing complications of the JP drain?

9 :
A nurse is caring for a patient in the immediate post-operative period following abdominal surgery. Which of the following assessments is the highest priority during the first hour post-op?