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HESI: Perioperative Care Questions And Correct
Detailed Answers (Verified Answers) Already Graded A+
Preoperative & Postoperative Nursing Assessment Questions
- Question: After completing the admission interview, the nurse reviews the client's
- Question: Which question is most important for the nurse to ask the client during the
- Question: After the client stops crying, she states, "My father was in so much pain
- Question: While discussing postoperative pain management strategies with the client,
medical record and notes that the surgical consent form is filled out but is not signed by the client. What action should the nurse take?Correct Answer: Ask the client if she has received sufficient information to sign the consent form.Rationale: The nurse may witness the client's signature if the nurse is able to determine that the client has been sufficiently informed of the necessary information.
admission interview?Correct Answer: "Have you had anything to eat or drink since midnight?" Rationale: Ensuring that the client has remained NPO for the prescribed length of time before surgery is critical to prevent vomiting and aspiration during surgery.
before he died. Talking about pain brings back so many memories." How should the nurse respond?Correct Answer: "It sounds as if you went through a difficult time when your father died." Rationale: This open-ended acknowledgment of the client's distress is therapeutic and allows the opportunity for further discussion by the client if desired.
the nurse observes them begin to cry. What action should the nurse take?
Correct Answer: Quietly sit with the client.
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Rationale: Offering one's presence is a caring and therapeutic response.
- Question: The nurse discusses postoperative pain management with the client and
- Question: When the nurse begins teaching about the benefits of early mobilization
- Question: The nurse talks with the client about what to expect the day of surgery and
explains the use of a patient-controlled analgesia (PCA) pump. The client expresses fear that they might accidentally overdose herself, since they will be sleepy after surgery. How should the nurse respond?Correct Answer: "The pump has a control device that prevents you from taking too much medicine." Rationale: This response provides the client with the information needed to understand that she cannot overdose herself while she is sedated after surgery.
following surgery, the client states, "Oh, I know if I stay in bed very long I will get bedsores." How should the nurse respond?Correct Answer: "Bedsores are one of many problems that can occur from prolonged bedrest." Rationale: This response acknowledges the client's previous learning and promotes further learning related to other complications of immobility such as thrombus formation, constipation, and atelectasis.
during the immediate postoperative period. The nurse provides instructions regarding cough and deep breathing exercises. The client performs a return demonstration by breathing in deeply through their mouth and exhaling forcefully and rapidly through pursed lips. What action should the nurse implement?
Correct Answer: Demonstrate the deep breathing and coughing technique again.
Rationale: The client has demonstrated incorrect technique. When performing deep breathing exercises, the client should inhale through the nose and exhale slowly through the mouth without pursing the lips. The nurse should demonstrate the entire procedure again for best learning by the client.
- Question: The nurse then reviews the client's preoperative lab test results drawn earlier
in the week. Which serum lab value requires follow-up by the nurse?
Correct Answer: WBC of 14,000/μL (4.0 x 109/L).
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Rationale: The normal WBC count is 4,000 to 10,000/μL (4.0-10 x 109/L). An increase may indicate the onset of an infection, which may be a contraindication to surgery. The nurse should notify the surgeon of this abnormal lab value.
- Question: The nurse reviews the client's medications. The client indicates that she has
been taking two medications; hydrochlorothiazide, a diuretic, and warfarin, an anticoagulant, every day for more than a year. What nursing action is most important?
Correct Answer: Explain the need to withhold the warfarin prior to surgery.
Rationale: Anticoagulants increase the risk for bleeding during surgery and the
postoperative period, so the nurse must explain the need to withhold the warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before surgery the medication should be stopped.
- Question: The nurse begins the preoperative assessment by taking the client's vital
signs. Which vital sign requires follow-up by the nurse?
Correct Answer: BP of 160/88 mmHg.
- Question: The nurse observes that the word, "Yes" has been marked on the client's left
hip, and the word, "No" has been written on their right hip. What action should the nurse implement?
Correct Answer: Confirm that the left hip is the site of the scheduled surgery.
Rationale: The nurse should ensure that the markings on the hips are correct to help reduce the potential for error during surgery. When the surgical site involves a distinction between left and right sides of the body, marking the site is a required component of The Joint Commission's universal protocol to prevent wrong site, wrong procedure, wrong person surgery.
- Question: The client is transferred to a stretcher and taken to the operating room (OR).
The nurse assists the client off the stretcher and onto the OR table. After general anesthesia is induced, the nurse positions the client for surgery. Which nursing diagnosis has the highest priority at this time?
Correct Answer: Risk for perioperative-positioning injury.
Rationale: During surgery the client may remain in one position for a prolonged period. The nurse must ensure that the client is protected from injury secondary to inappropriate positioning.
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- Question: Once the OR team has assembled in the room, the circulating nurse calls for
a time out. What action should the nurse take during the time out?
Correct Answer: Review the scheduled procedure, site, and client.
Rationale: A time out, the designated method for final verification before surgery begins, is a component of The Joint Commission's universal protocol to prevent wrong site, wrong procedure, wrong person surgery.
- Question: The surgery is successfully completed without complications. Following
surgery, the client is admitted to the Post Anesthesia Care Unit. The operative report indicates that the client had a left hip replacement under general anesthesia. The initial nursing assessment reveals that the client is not responding to verbal stimuli. Their vital signs are T 97.6° F (36.4° C), P 88, R 14, and BP 130/70. What action should the nurse implement first?
Correct Answer: Position the client on her side.
Rationale: During the immediate postanesthesia period, the unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions.
- Question: While assessing the client, the nurse observes that the surgical dressing is in
place on the left hip, with no visible drainage. How should the nurse document this finding?
Correct Answer: Left hip dressing clean, dry, and intact.
Rationale: This documentation is concise but thorough, providing a clear picture of the assessed data.
- Question: When the client arrives on the unit, the nurse notes that their IV is wide
open. Review of the client's postoperative prescriptions indicates that sodium chloride 0.9% is to infuse at 75 mL/hour, alternating with Lactated Ringer's solution at 75 mL/hour.An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 15 drops/mL and resets the IV. At what rate in drops/min, should the IV infuse?
Correct Answer: 19 drops per minute.
Rationale: 75 mL/60 minutes × 15 gtts/1 mL = 18.75, which rounds up to 19.
- Question: While the nurse begins to assess the client, another nurse finds an infusion
pump and prepares a prescribed "now" dose of an intravenous antibiotic. The prescription is for 2 grams of cefazolin, which arrives from the pharmacy diluted in 50 mL of sodium
