Page 500 - Saunders Comprehensive Review For NCLEX-RN

postoperative period. The nurse would become most concerned with which
sign that could indicate an evolving complication?
1. Increasing restlessness
2. A pulse of 86 beats per minute
3. Blood pressure of 110/70 mm Hg
4. Hypoactive bowel sounds in all 4 quadrants
135. A client who has had abdominal surgery complains of feeling as though
“something gave way” in the incisional site. The nurse removes the dressing
and notes the presence of a loop of bowel protruding through the incision.
Which interventions should the nurse take? Select all that apply.
1. Contact the surgeon.

2. Instruct the client to remain quiet.

3. Prepare the client for wound closure.
4. Document the findings and actions taken.

5. Place a sterile saline dressing and ice packs over the wound.

6. Place the client in a supine position without a pillow under
the head.
136. A client who has undergone preadmission testing has had blood drawn for
serum laboratory studies, including a complete blood count, coagulation
studies, and electrolytes and creatinine levels. Which laboratory result
should be reported to the surgeon’s office by the nurse, knowing that it could
cause surgery to be postponed?
1. Hemoglobin, 8.0 g/dL (80 mmol/L)
2. Sodium, 145 mEq/L (145 mmol/L)
3. Serum creatinine, 0.8 mg/dL (70.6 mcmol/L)
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4. Platelets, 210,000 cells/mm (210 × 10 /L)
137. The nurse receives a telephone call from the postanesthesia care unit stating
that a client is being transferred to the surgical unit. The nurse plans to take
which action first on arrival of the client?
1. Assess the patency of the airway.
2. Check tubes or drains for patency.
3. Check the dressing to assess for bleeding.
4. Assess the vital signs to compare with preoperative
measurements.
138. The nurse is reviewing a surgeon’s prescription sheet for a preoperative
client that states that the client must be nothing by mouth (NPO) after
midnight. The nurse should call the surgeon to clarify that which medication
should be given to the client and not withheld?
1. Prednisone
2. Ferrous sulfate
3. Cyclobenzaprine
4. Conjugated estrogen

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