Pre/Intra/Post Op
A nurse reviews the chart of a patient scheduled for surgery. Which finding requires immediate follow-up?
What is potassium 2.9 mEq/L?
Reason: Hypokalemia increases risk for cardiac arrhythmias during anesthesia (ADPIE -clinical judgement - intervention)
A nurse auscultates wheezing throughout the lung fields in a client reporting dyspnea. What does this most likely indicate?
1. Bronchoconstriction
2. Pulmonary edema
3. Complete airway obstruction
4. Bronchodilatation
What is bronchoconstriction?
Rationale: Wheezing suggests narrowed airways, common in asthma or bronchospasm. (Clinical Judgment Model – Analyze Cues-implementation)
A COPD client is post-op with SpO₂ 88% on room air. Which oxygen delivery method is most appropriate?
A. Simple mask at 10L/min
B. Non-rebreather mask at 15 L/min
C. Venturi mask at 50% FiO₂.
D. Nasal cannula at 2 L/min
What is nasal cannula?
Rationale: Provides low-flow oxygen without suppressing respiratory drive (clin judge - cues - planning/implement)
Which patient is most at risk for metabolic acidosis?
A. Patient with diabetic ketoacidosis
B. Patient with prolonged vomiting
C. Patient with COPD
D. Patient with anxiety-induced hyperventilation
What is patient with diabetic ketoacidosis?
Rationale: DKA causes increased acid production.
Clinical Judgment Model – Recognize Cues -planning
A client reports chest pain on exertion relieved by rest. What does this most likely indicate?
A. Unstable angina
B. Stable angina
C. Myocardial infarction
D. Pulmonary embolism
What is stable angina?
Rationale: Pain relieved by rest suggests chronic ischemia. Clinical Judgment Model Recognize Cues- implementation
During surgery, the patient’s temperature rises to 104°F, heart rate 130 bpm, and muscle rigidity is noted. What is the nurse’s priority interpretation?
What is malignant hyperthermia?
reason: Life-threatening reaction to anesthesia requiring immediate intervention. (Clinical judgment - analyzing cues- planning)
Which client should the nurse assess first?
A. Client with sinusitis reporting facial pain
B. Client with pneumonia and SpO₂ 84%
C. Client with COPD reporting mild shortness of breath
D. Client with bronchitis requesting cough syrup
Who is the client with pneumonia and SpO₂ 84%?
Rationale: Airway and oxygenation take priority (ABC)
Which nursing diagnosis is most appropriate for a COPD client admitted with pneumonia?
A. Activity intolerance related to oxygen supply and demand
B. Impaired gas exchange related to ventilation-perfusion inequality
C. Ineffective airway clearance related to inhalation of toxins
D. Risk for infection related to presence of catheter
What is Impaired gas exchange?
Rationale: Primary problem is oxygenation impairment.(clin judge - prioritize- DX)
Why is an Allen test performed before drawing ABGs?
A. To ensure radial artery is patent
B. To test for peripheral arterial disease
C. To determine capillary refill time
D. To confirm adequate perfusion via the ulnar artery
What is confirm adequate perfusion via the ulnar artery ?
Rationale: Confirms collateral circulation before puncture. (Clinical Judgment Model – Analyze Cues - planning )
What ECG change most strongly suggests ischemia?
A. T-wave inversion
B. P-wave inversion
C. Q-wave changes
D. ST elevation
what is T-wave inversion?
Rationale: Indicates myocardial oxygen deprivation.
Clinical Judgment Model – Analyze Cues -planning
A nurse assesses four post-op patients. Which one is at highest risk for impaired gas exchange?
Who is the patient with SpO₂ 86% on room air?
reason: Airway and breathing take priority in ABC framework
A school-age child is having an asthma attack. What is the preferred intervention?
A. Beta-adrenergic agonist
B. High-flow oxygen and prepare for intubation
C. Inhaled corticosteroid
D. Long acting antagonist inhaler
What is administer an inhaled beta-adrenergic agonist?
Rationale: Short-acting beta-agonists relieve bronchospasm quickly. (Clin Judge - Act -plan/ intervention)
What teaching should the nurse emphasize for a client with COPD?
A. Avoid indoor toxins and cluster ADLs to conserve energy
B. Smoking up to three cigarettes weekly is allowable
C. Minor respiratory infections are self-limited
D. Increase caffeine intake to promote drainage
What is avoid indoor toxins and cluster ADLs to conserve energy ?
Rationale: Prevent exacerbations and manage fatigue. Maslow – Physiological
Which condition is most likely to cause respiratory acidosis?
A. Vomiting
B. Asthma exacerbation
C. Diarrhea
D. Hyperventilation
What is Asthma exacerbation?
Rationale: Hypoventilation leads to CO₂ retention.
Clinical Judgment Model – Prioritize Hypothesis -DX
Which vessel is most commonly used for CABG?
A. Brachial artery
B. Femoral artery
C. Greater saphenous vein
D. Radial artery
What is the Greater saphenous vein?
Rationale: Provides adequate length and caliber for grafting. Clinical Judgment Model – Prioritize Hypothesis - DX
A patient is 1 hour post-op and reports nausea and vomiting. What is the best initial intervention?
What is administer antiemetic as prescribed?
reason: Prevents aspiration and promotes comfort. (Maslow's -phys. needs and ADPIE -intervention)
After teaching incentive spirometry, which finding shows effectiveness?
A. The client use the spirometer every 2 hours with increase pulse ox between 95-96%
B. The client uses the spirometer once daily after waking up with pulse ox of 90%
C. The client exhales forcefully into the spirometer to clear secretions with pulse ox of 94%
D. The client reports feeling dizzy after each use with a pulse ox of 88%
What is SpO₂ improves with spirometer every 2 hours with increase pulse ox between 95-96%?
Rationale: Indicates improved lung expansion and oxygenation. (Clinical Judgment Model - Outcomes)
Which COPD client should the nurse see first?
A. Client with mild dyspnea
B. Client with productive cough
C. Client requesting pain medication
D. Client with SpO₂ 82%
What is Client with SpO₂ 82% ?
Rationale: Oxygenation is priority.
Framework: ABC
A client’s ABG shows pH 7.30, PaCO₂ 55 mmHg. What is the priority intervention?
A. Administer sodium bicarbonate
B. Encourage slow shallow breathing and coughing
C. Restrict fluids
D. Encourage deep breathing and coughing
What is encourage deep breathing and coughing?
Rationale: Improves ventilation and CO₂ elimination - ABC
A client with suspected MI arrives at the ED. What is the priority intervention?
A. Administer oxygen and prepare for thrombolytic therapy
B. Give aspirin 81 mg and send for chest X-ray
C. Start IV fluids and monitor urine output
D. Provide emotional support
What is Administer oxygen and prepare for thrombolytic therapy?
Rationale: Restores perfusion and prevents further damage. ABC
After applying incentive spirometry teaching, which finding indicates the intervention was effective?
What is SpO₂ improves from 90% to 96%?
reason: Demonstrates improved oxygenation and lung expansion (ADPIE - evaluating outcomes)
A client with acute sinusitis asks how to promote drainage at home. What should the nurse recommend?
A. Increase fluid intake
B. Apply warm, moist compresses to the face several times a day
C. Sleep flat on the back to reduce pressure
D. Use a warm or cool mist humidifier in the bedroom
What is increase fluid intake?
Rationale: Hydration thins secretions, promoting drainage (Maslow- physiological need).
After teaching pursed-lip breathing, which statement shows understanding?
A. “I will inhale quickly and exhale slowly through pursed lips.”
B. “I will hold my breath for 10 seconds after inhaling.”
C. “I will exhale slowly through pursed lips to prevent airway collapse.”
D. “I will breathe only through my nose.”
What is exhale slowly through pursed lip to prevent airway collapse?
Rationale: Technique improves ventilation and reduces air trapping. Clinical Judgment Model – Evaluate Outcomes -evaluation
After implementing interventions for metabolic alkalosis, which finding shows improvement?
A. Blood pH returns to 7.35–7.45
B. PaCO₂ increases to 60 mmHg
C. SpO₂ decreases to 88%
D. Serum potassium drops further
What is the blood pH returns to 7.35–7.45?
Rationale: Indicates correction of acid-base imbalance. Clinical Judgment Model – Evaluate Outcomes -evaluation
After nitroglycerin administration, which finding indicates effectiveness?
A. SpO₂ decreases to 88%
B. Heart rate increases to 120 bpm
C. BP drops to 80/50 mmHg
D. Chest pain relief within minutes
What is chest pain relief within minutes?
Rationale: Confirms improved coronary perfusion. Clinical Judgment Model – Evaluate Outcomes -evaluation