Surgery
Which finding is most concerning for a patient 2 hrs postop?
A. 15 ml urine output
B. Pain rating of 6
C. Heart rate of 105
D. Sanguineous drainage
The correct answer is C
The others can be considered expected at this stage of recovery.
A nurse notes a client in early shock has urine output of 20 mL/hr. What does this indicate?
A. Kidney failure
B. Adequate perfusion
C. Oliguria
D. Fluid overload
The correct answer is C
Rationale:
Oliguria (low urine output) occurs because blood is being redirected to vital organs like the brain and heart.
Normal urine output is at least 30 mL/hr.
A client with suspected septic shock has an oxygen saturation of 88% on room air. What is the nurse’s priority action?
A. Insert urinary catheter
B. Administer O2 via nonrebreather mask
C. Start antihypotensive IV
D. Obtain lab work
Rationale: Airway and breathing take priority. Hypoxia must be corrected before circulation interventions.
Which of these is not a potential responsibility of the nurse during informed consent?
A. Being a witness
B. Ensuring the patient understands the meaning of the consent form
C. Making sure the consent form is being signed voluntarily
D. Answering any questions the patient has about the risks of the procedure after the surgeon has left.
The answer is D.
Only the surgeon can explain the procedure and the complications the nurses responsibility is to act as an advocate.
Distributive shock includes which of the following types of shock? Select all that apply.
A. Anaphylactic shock
B. Hypovolemic shock
C. Septic shock
D. Neurogenic shock
E. Cardiogenic shock
The correct answers areA,C,D
Rationale: The issue in all of these is the distribution because of decreased peripheral vascular resistance as opposed to poor cardiac output or decreased blood volume.
Which IV solution is most appropriate for initial treatment of hypovolemic shock?
A. 0.9% NS
B. D5W
C. 0.45% saline
D. 3% saline
The correct answer is A
Rationale:
Isotonic solutions expand intravascular volume.
D5W becomes hypotonic.
0.45% saline is hypotonic.
3% saline is hypertonic and not first-line.
A nurse is assessing a client 24 hours post abdominal surgery. The client reports cramping abdominal pain and nausea. The abdomen is distended and firm. Bowel sounds are absent in all quadrants. The client has not passed flatus.
Which postoperative complication does the nurse suspect?
A. Peritonitis
B. Paralytic ileus
C. Hypovolemic shock
D. Dumping syndrome
Answer is B
Clues:
After abdominal surgery, the intestines temporarily “go to sleep.” That is paralytic ileus.
A client is suspected of being in early shock. Which findings support this?
Select all that apply.
A. Urine output 25 mL/hr
B. Heart rate 118 bpm
C. Respiratory rate 24/min
D. Blood pressure 120/80 mm Hg
E. Heart rate 58 bpm
The Correct Answers are A, B, C, D
Rationale:
25 mL/hr = decreased urine
HR 118 = tachycardia
RR 24 = tachypnea
Normal blood pressure can still be present in early shock.
HR 58 is bradycardia (late finding).
Which finding indicates the client is in the compensatory stage of shock?
A. Blood pressure 78/40 mm Hg
B. Decreased urine output
C. Tachycardia and tachypnea
D. Bradycardia and bounding pulses
The correct answer is C.
Rationale: In early compensatory shock, the sympathetic nervous system increases heart rate and respiratory rate to maintain perfusion. Hypotension occurs later.
A nurse is reinforcing preoperative teaching with a client scheduled for elective surgery under general anesthesia. Which of the following statements by the client indicate correct understanding of teaching?
Select all that apply.
A. “I will stop taking my warfarin several days before surgery as directed.”
B. “I can drink clear liquids up to 2 hours before the procedure.”
C. “I will practice deep breathing exercises every hour after surgery.”
D. “I should avoid smoking for at least 24 hours before surgery.”
E. “Once I sign the consent form, I cannot change my mind.”
F. “I should report if I develop a cold or fever before surgery.”
The correct answers are A, C, D, F
A. Stop warfarin
Correct. Anticoagulants increase bleeding risk. They are stopped several days before surgery.
C. Deep breathing every hour
Correct. Prevents atelectasis and pneumonia after surgery.
D. Avoid smoking
Correct. Smoking affects oxygenation and healing. At least 24 hrs (preferably weeks).
F. Report cold or fever
Correct. Infection before surgery can delay procedure.
B. Clear liquids up to 2 hours
Wrong. This applies to procedural sedation, not general anesthesia surgery. Most general surgeries require NPO after midnight
E. Cannot change mind after signing consent
Wrong. Consent can be withdrawn at any moment, even after signing.
What type of shock should be expected if a patient presents with edema and labored breathing?
A. Anaphylactic shock
B. Cardiogenic shock
C. Obstructive shock
D. Neurogenic shock
The correct answer is B
Rationale: Cardiogenic shocks signs and symptoms can mimic the symptoms of HF. The other forms of shock have more traditional signs and symptoms like tachycardia, hypotension, oliguria or appear more like an allergic reaction with urticaria and wheezing.
Key clues in the question: Edema, labored breathing!
A client in shock becomes lethargic with shallow respirations. What is the first action?
A. Call rapid response
B. Assess airway patency
C. Administer IV fluids
D. Check blood pressure
The correct answer is B
Rationale: Airway assessment comes before calling for assistance or treating circulation.
A nurse in the PACU is caring for an elderly Patient 45 minutes after abdominal surgery under general anesthesia. The client’s vital signs are BP 84/50 mm Hg, HR 124/min, RR 24/min, SpO₂ 92% on 2 L nasal cannula. The skin is pale, cool, and clammy. Urine output over the last 30 minutes is 10 mL. The surgical dressing has a small amount of drainage.
What is the nurse’s priority action?
A. Increase the oxygen to 6 L/min via nasal cannula
B. Notify the surgeon immediately
C. Recheck vital signs in an hour
D. Administer prescribed IV opioid medication
The correct answer is B.
Look at the clues:
These are indicative of hypovolemic shock which is an emergency the surgeon needs to be notified immediately in order to prevent it from reaching the irreversible stage. The other options may be correct but are not the priority action
A resident in shock is most likely experiencing which condition?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
The correct answer is B.
Rationale:The anaerobic metabolism which occurs as a result of hypoxia produces lactate which leads to lactic acid build up in the bloodstream and results in metabolic acidosis.
A client with cardiogenic shock has:
The provider prescribes a 1L normal saline bolus.
What is the nurse’s best action?
A. Administer bolus rapidly
B. Question the prescription
C. Place client flat
D. Increase O2 to 2 L
The correct answer is B.
Rationale:
Cardiogenic shock = pump failure.
Signs of fluid overload:
A fluid bolus may worsen pulmonary edema.