Pharmacology
A patient is receiving heparin infusion for a DVT. The new aPTT is 110 seconds. What is the nurse's priority?
A. Increase the infusion rate
B. Stop the infusion
C. Administer vitamin K
D. Document and recheck in 6 hrs
Correct answer: B.
Rationale: Therapeutic aPTT is typically ~60-80 seconds. A value of 110 is supra therapeutic and increases bleeding risk.
A client is scheduled for a bowel resection. The nurse witnesses the client sign the consent form. Which statement by the client requires immediate follow-up?
A. “The surgeon explained the risks of bleeding.”
B. “I understand I may need a temporary ostomy.”
C. “The nurse told me everything about the surgery.”
D. “I had a chance to ask questions.”
Answer: C. “The nurse told me everything about the surgery.”
Rationale:
The surgeon is responsible for explaining the procedure, risks, benefits, and alternatives. If the client believes the nurse provided surgical explanation, clarification is required. The nurse may witness the signature but cannot obtain informed consent.
A client is 4 hours post-op following a bowel resection. Which finding requires immediate action?
A. Absent bowel sounds
B. Pain rated 6/10
C. BP 88/54 and HR 118
D. Small amount of serosanguineous drainage
Answer: C. BP 88/54 and HR 118
Rationale:
Hypotension + tachycardia suggests hemorrhage or hypovolemic shock and requires immediate intervention. Absent bowel sounds are expected early post-op. Mild drainage and moderate pain are expected.
The nurse is assessing a client with abdominal pain. In what order should the nurse perform the assessment?
A. Palpate → Percuss → Auscultate → Inspect
B. Inspect → Auscultate → Percuss → Palpate
C. Auscultate → Inspect → Palpate → Percuss
D. Inspect → Palpate → Percuss → Auscultate
Answer: B. Inspect → Auscultate → Percuss → Palpate
Rationale:
The abdomen is assessed differently than other systems. Auscultation must occur before percussion and palpation to avoid altering bowel sounds.
A client is 6 hours post-op following a splenectomy. Which finding requires immediate action?
A. Pain rated 7/10
B. BP 86/48 and HR 124
C. Absent bowel sounds
D. Small amount of serosanguineous drainage
Answer: B. BP 86/48 and HR 124
Rationale:
Hypotension with tachycardia suggests hemorrhage and hypovolemic shock — a life-threatening complication. Early post-op bowel sounds are often absent and mild drainage is expected.
A patient with heart failure is prescribed metoprolol 50 mg PO. Before administering the medication, which assessment finding requires the nurse to hold the medication?
A. BP 142/86
B. HR 54
C. RR 18
D. BNP 380
Answer: B. HR 54
Rationale:
Beta blockers lower heart rate. A heart rate < 60 bpm is a reason to hold and notify the provider. Blood pressure is acceptable, and BNP elevation alone does not require holding the medication.
A client scheduled for total hip replacement takes warfarin daily. Which laboratory value must the nurse report to the provider before surgery?
A. INR 2.5
B. Hemoglobin 12.8
C. Platelets 210,000
D. Potassium 4.1
Answer: A. INR 2.5
Rationale:
Warfarin increases bleeding risk. An INR of 2.5 is therapeutic for anticoagulation but unsafe for surgery. It must be addressed pre-operatively. The other labs are within normal range.
Orthopedic Surgery (Neurovascular Assessment)
A client is 6 hours post-op from a tibial fracture repair. Which finding is MOST concerning?
A. Mild swelling at incision site
B. Pain 8/10 relieved by medication
C. Pain 9/10 not relieved by opioids
D. Warm extremity with cap refill 2 seconds
Answer: C. Pain 9/10 not relieved by opioids
Rationale:
Severe pain unrelieved by medication is an early sign of compartment syndrome. This is a surgical emergency. Swelling and moderate pain are expected.
A client is 8 hours post-op following abdominal surgery. Which assessment finding is most concerning?
A. Absent bowel sounds
B. Temp 99.1°F
C. Increasing abdominal distention and HR 120
D. Pain at incision site
Answer: C. Increasing abdominal distention and HR 120
Rationale:
Distention + tachycardia may indicate internal bleeding or developing ileus. This requires immediate evaluation. Absent bowel sounds early post-op are expected.
A client is 24 hours post-op from a femur fracture repair. Which assessment findings suggest fat embolism syndrome? (Select all that apply.)
A. Sudden shortness of breath
B. Petechiae on chest
C. Confusion
D. Bradycardia
E. Hypoxemia
Answers: A, B, C, E
Rationale:
Classic signs of fat embolism syndrome:
Respiratory distress
Hypoxemia
Neurological changes (confusion)
Petechial rash
Bradycardia is not typical; tachycardia is more common.
A patient receiving warfarin has an INR of 4.5. What is the nurse’s priority action?
A. Administer scheduled dose
B. Hold the medication and notify provider
C. Encourage green leafy vegetables
D. Administer vitamin K immediately
Answer: B. Hold the medication and notify provider
Rationale:
Therapeutic INR is typically 2–3. An INR of 4.5 increases bleeding risk. The nurse should hold the dose and notify the provider. Vitamin K is given for significant bleeding or critically high INR, not automatically.
The nurse prepares a client for a scheduled appendectomy at 1000. When should prophylactic IV antibiotics be administered?
A. The night before surgery
B. Immediately after surgery
C. Within 60 minutes before incision
D. When the client arrives in PACU
Answer: C. Within 60 minutes before incision
Rationale:
Prophylactic antibiotics must be given within 60 minutes prior to incision to reduce surgical site infection risk. This is a key NCLEX safety principle.
On post-op day 1 after abdominal surgery, a client has shallow respirations and refuses to use the incentive spirometer due to pain. What is the nurse’s priority action?
A. Document refusal
B. Encourage ambulation
C. Administer prescribed pain medication
D. Notify the provider
Answer: C. Administer prescribed pain medication
Rationale:
Pain limits deep breathing and increases risk for atelectasis and pneumonia. Pain control enables participation in pulmonary hygiene. Address the barrier first.
A client has a cast applied to the lower leg. Which finding requires immediate action?
A. Toes warm and pink
B. Cap refill 2 seconds
C. Tingling and numbness in toes
D. Mild swelling
Answer: C. Tingling and numbness in toes
Rationale:
Paresthesia is an early sign of compartment syndrome. Neurovascular compromise must be addressed immediately.
On post-op day 4 after abdominal surgery, a client reports a “popping” sensation at the incision site. The nurse observes separation of the incision edges without organ protrusion. What complication has occurred?
A. Evisceration
B. Surgical site infection
C. Dehiscence
D. Seroma
Answer: C. Dehiscence
Rationale:
Dehiscence is partial or total separation of wound edges. Evisceration occurs when organs protrude.
A post-operative patient is prescribed morphine 2 mg IV PRN pain. The patient is difficult to arouse and has RR 8/min. What is the nurse’s first action?
A. Administer naloxone
B. Apply oxygen
C. Call rapid response
D. Attempt to stimulate the patient
Answer: D. Attempt to stimulate the patient
Rationale:
The FIRST action is to stimulate the patient. If respirations do not improve, then administer naloxone. NCLEX tests “least invasive first” and assessment before intervention.
A client with a fractured femur is scheduled for surgical repair. Which assessment finding requires immediate action?
A. Pain rated 7/10
B. Cap refill 2 seconds
C. Cool foot with weak pedal pulse
D. Anxiety about surgery
Answer: C. Cool foot with weak pedal pulse
Rationale:
A cool extremity with weak pulse suggests compromised circulation and possible compartment syndrome or vascular injury. This is a priority over pain or anxiety.
A client is 2 days post-op from total hip replacement. Which findings suggest possible DVT? (Select all that apply.)
A. Unilateral leg swelling
B. Calf warmth
C. Positive Homan’s sign
D. Sudden shortness of breath
E. Calf pain on palpation
Answers: A, B, E
Rationale:
Swelling, warmth, and calf pain suggest DVT.
Homan’s sign is unreliable and not recommended.
Sudden SOB suggests PE, not DVT itself.
Which assessment finding is an early sign of compartment syndrome after orthopedic surgery?
A. Absent pulse
B. Pallor
C. Severe pain unrelieved by medication
D. Paralysis
Answer: C. Severe pain unrelieved by medication
Rationale:
Pain out of proportion to injury and unrelieved by opioids is the earliest and most reliable sign. Pulselessness and paralysis are late findings.
A client 8 hours after tibial fracture repair reports increasing pain despite opioid administration. The extremity is tense and firm. What is the nurse’s priority action?
A. Elevate the extremity higher than the heart
B. Apply ice
C. Notify the provider immediately
D. Reassess in 30 minutes
Answer: C. Notify the provider immediately
Rationale:
Findings suggest compartment syndrome, a surgical emergency. Immediate provider notification is required. Elevating above heart level can worsen arterial perfusion.
The nurse is teaching a patient about rapid-acting insulin (lispro). Which statements indicate understanding? (Select all that apply.)
A. “I will take this insulin 30 minutes before meals.”
B. “I should eat within 15 minutes of taking this insulin.”
C. “This insulin works quickly.”
D. “I can skip meals after taking this insulin.”
E. “This insulin helps control blood sugar after meals.”
Answers: B, C, E
Rationale:
Lispro works quickly (onset ~15 minutes).
Patient must eat within 15 minutes.
It controls postprandial glucose.
It is NOT given 30 minutes before meals (that is regular insulin).
Skipping meals risks hypoglycemia.
The nurse is teaching a client scheduled for abdominal surgery. Which instructions should the nurse include? (Select all that apply.)
A. “Use the incentive spirometer after surgery.”
B. “You will need to cough and deep breathe.”
C. “Avoid moving in bed after surgery.”
D. “You may have sequential compression devices.”
E. “You will likely receive pain medication.”
Answers: A, B, D, E
Rationale:
Incentive spirometer prevents atelectasis.
Coughing/deep breathing prevents pneumonia.
SCDs prevent DVT.
Pain control is expected.
Avoiding movement is incorrect — early ambulation is encouraged.
A client 2 days post-op abdominal surgery reports a “popping” sensation at the incision site. The nurse notes bowel protruding through the incision. What is the nurse’s FIRST action?
A. Apply abdominal binder
B. Call rapid response
C. Cover with sterile saline-soaked dressings
D. Attempt to gently push bowel back in
Answer: C. Cover with sterile saline-soaked dressings
Rationale:
For evisceration, the nurse should cover the wound with sterile saline-moistened dressings to prevent tissue drying and infection. Do NOT attempt to reinsert bowel.
A client is 24 hours post-op abdominal surgery. Which assessment findings may indicate developing atelectasis? (Select all that apply.)
A. Diminished breath sounds
B. Low-grade fever
C. Shallow respirations
D. Productive cough with thick sputum
E. O2 saturation 88%
Answers: A, B, C, E
Rationale:
Diminished breath sounds
Low-grade fever
Shallow breathing
Decreased oxygen saturation
These are consistent with atelectasis. Thick productive sputum is more suggestive of pneumonia.
A client 3 days post-op abdominal surgery suddenly develops chest pain and shortness of breath. What is the nurse’s first action?
A. Place client in high Fowler’s position
B. Administer PRN pain medication
C. Encourage deep breathing
D. Document findings
Answer: A. Place client in high Fowler’s position
Rationale:
Suspected pulmonary embolism requires immediate oxygenation support. Positioning the client upright improves ventilation while additional help is obtained.