Page 499 - Saunders Comprehensive Review For NCLEX-RN

1. Avoid oral hygiene and rinsing with mouthwash.
2. Verify that the client has not eaten for the last 24 hours.
3. Have the client void immediately before going into surgery.
4. Report immediately any slight increase in blood pressure or pulse.
129. A client with a gastric ulcer is scheduled for surgery. The client cannot sign
the operative consent form because of sedation from opioid analgesics that
have been administered. The nurse should take which most appropriate
action in the care of this client?
1. Obtain a court order for the surgery.
2. Have the charge nurse sign the informed consent immediately.
3. Send the client to surgery without the consent form being signed.
4. Obtain a telephone consent from a family member, following
agency policy.
130. A preoperative client expresses anxiety to the nurse about upcoming
surgery. Which response by the nurse is most likely to stimulate further
discussion between the client and the nurse?
1. “If it’s any help, everyone is nervous before surgery.”
2. “I will be happy to explain the entire surgical procedure to you.”
3. “Can you share with me what you’ve been told about your
surgery?”
4. “Let me tell you about the care you’ll receive after surgery and the
amount of pain you can anticipate.”
131. The nurse is conducting preoperative teaching with a client about the use of
an incentive spirometer. The nurse should include which piece of
information in discussions with the client?
1. Inhale as rapidly as possible.
2. Keep a loose seal between the lips and the mouthpiece.
3. After maximum inspiration, hold the breath for 15 seconds and
exhale.
4. The best results are achieved when sitting up or with the head of
the bed elevated 45 to 90 degrees.
132. The nurse has conducted preoperative teaching for a client scheduled for
surgery in 1 week. The client has a history of arthritis and has been taking
acetylsalicylic acid. The nurse determines that the client needs additional
teaching if the client makes which statement?
1. “Aspirin can cause bleeding after surgery.”
2. “Aspirin can cause my ability to clot blood to be abnormal.”
3. “I need to continue to take the aspirin until the day of surgery.”
4. “I need to check with my doctor about the need to stop the aspirin
before the scheduled surgery.”
133. The nurse assesses a client’s surgical incision for signs of infection. Which
finding by the nurse would be interpreted as a normal finding at the surgical
site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm, tender skin
134. The nurse is monitoring the status of a postoperative client in the immediate

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