24 original SNLE questions on surgical nursing, each with an explanation for all four options. Part of Adult Nursing, worth 40% of the Saudi Nursing Licensure Examination.
Q01 / 10hard0 correct
Adult Nursinghardq006
Two days after a total thyroidectomy, a patient reports tingling around the mouth and in the fingertips. On assessment, carpal spasm occurs when the blood pressure cuff is inflated. Which action should the nurse take first?
All 24 questions
Every question below, with the reasoning for all four options. Try to answer before you open one.
Surgical nursing · hard
Two days after a total thyroidectomy, a patient reports tingling around the mouth and in the fingertips. On assessment, carpal spasm occurs when the blood pressure cuff is inflated. Which action should the nurse take first?
AReassure the patient that paresthesia is an expected postoperative finding
BEncourage deep breathing into a paper bag to correct respiratory alkalosis
CNotify the physician and prepare to administer intravenous calcium gluconate
DAdminister the scheduled levothyroxine dose several hours early
Show the answer and why the others fail
Answer: C. Notify the physician and prepare to administer intravenous calcium gluconate
A
These are not benign findings; dismissing them delays treatment of a potentially life-threatening electrolyte emergency.
B
This addresses hyperventilation-induced symptoms, which is not the mechanism here; the post-thyroidectomy context points strongly to true hypocalcemia.
C — correct
Perioral and digital paresthesia with a positive Trousseau sign indicates acute hypocalcemia from inadvertent parathyroid injury or removal. This can progress to laryngospasm and tetany, so urgent calcium replacement is required.
D
Levothyroxine replaces thyroid hormone and has no effect on serum calcium; it does not treat this emergency.
TakeawayPerioral tingling plus Trousseau or Chvostek sign after thyroidectomy signals hypocalcemia from parathyroid injury — anticipate IV calcium and watch for laryngospasm.
Surgical nursing · medium
A nurse is caring for a patient who had a chest tube inserted 2 hours ago for a spontaneous pneumothorax. The drainage system is a wet suction system with the suction control chamber set to 20 cm H2O, and the wall suction is adjusted to produce gentle continuous bubbling in that chamber. Which assessment finding indicates an air leak?
ASerosanguineous drainage in the collection chamber
BFluid fluctuation in the water seal chamber with respirations
CContinuous gentle bubbling in the suction control chamber
DContinuous bubbling in the water seal chamber
Show the answer and why the others fail
Answer: D. Continuous bubbling in the water seal chamber
A
Serosanguineous drainage is an expected finding after chest tube insertion and does not indicate an air leak.
B
Fluid fluctuation (tidaling) in the water seal chamber is a normal finding that reflects changes in intrapleural pressure during the respiratory cycle.
C
Continuous gentle bubbling in the suction control chamber is an expected finding in a wet suction system, indicating that the prescribed suction level is being maintained.
D — correct
Continuous bubbling in the water seal chamber indicates an air leak, either from the patient's pleural space or a system leak. This finding requires further assessment to determine the source and appropriate intervention.
TakeawayIn a chest drainage system, continuous bubbling in the water seal chamber indicates an air leak, which may be from the patient's pleural space or a system leak. Gentle, continuous bubbling in the suction control chamber of a wet suction system is expected and confirms that suction is being applied. Tidaling (fluid fluctuation) in the water seal chamber is a normal finding.
Surgical nursing · medium
A 65-year-old male patient is 12 hours post-operative following a laparoscopic cholecystectomy. He has a history of hypertension and obesity. He is alert and oriented, and his vital signs are stable. He has sequential compression devices (SCDs) in place and has been performing ankle pumps as instructed. The nurse notes that he has not yet ambulated and is reluctant to move due to incisional pain. Which of the following nursing actions is the priority to prevent venous thromboembolism?
AInstruct the patient to continue ankle pumps and leg exercises every hour while awake.
BAdminister prescribed opioid analgesic and encourage deep breathing exercises.
CAssist the patient to ambulate in the hallway after ensuring adequate pain control.
DEnsure the sequential compression devices are properly fitted and functioning.
Show the answer and why the others fail
Answer: C. Assist the patient to ambulate in the hallway after ensuring adequate pain control.
A
Leg exercises reduce venous stasis but are less effective than ambulation. The patient is already performing them, so reinforcing this is not the priority when ambulation is possible.
B
Administering an analgesic may reduce pain and facilitate ambulation, but it does not directly prevent VTE. The priority is to mobilize the patient once pain is controlled.
C — correct
Early ambulation is the most effective nursing intervention to prevent VTE by promoting venous return and reducing stasis, especially in a patient with risk factors like obesity and age. Pain control is a prerequisite, but the action of ambulation is the priority.
D
SCDs are already in place; ensuring they are functioning is important but is a lower priority than ambulation for a patient who is able to walk, as ambulation provides superior VTE prophylaxis.
TakeawayEarly ambulation is the most effective nursing intervention to prevent venous thromboembolism in stable postoperative patients.
Surgical nursing · medium
A 35-year-old patient is in the post-anesthesia care unit following an appendectomy under general anesthesia. The patient suddenly develops muscle rigidity, a heart rate of 130 beats/min, and a temperature of 39.2°C (102.5°F). Which action should the nurse take first?
AApply a cooling blanket to reduce the temperature.
BNotify the surgeon immediately.
CAdminister dantrolene as prescribed.
DAdminister acetaminophen as prescribed.
Show the answer and why the others fail
Answer: C. Administer dantrolene as prescribed.
A
Cooling measures are supportive but not the first priority; dantrolene administration is critical to stop the underlying crisis.
B
While the surgeon should be informed, the nurse's immediate priority is to administer dantrolene to treat the life-threatening malignant hyperthermia.
C — correct
Dantrolene is the specific antidote for malignant hyperthermia, a life-threatening reaction to certain anesthetics. It must be given immediately to halt the hypermetabolic process.
D
Acetaminophen is an antipyretic but will not treat the underlying hypermetabolic crisis of malignant hyperthermia; it is not the priority intervention.
TakeawayMalignant hyperthermia is a life-threatening hypermetabolic crisis triggered by certain anesthetics; the priority intervention is immediate administration of dantrolene.
Surgical nursing · medium
A nurse is caring for a client who is 4 days post-operative following an exploratory laparotomy. The client reports a sudden 'popping' sensation at the incision site. Upon inspection, the nurse notes a small amount of serosanguineous drainage and a visible loop of bowel protruding through the wound. Which action should the nurse take first?
ANotify the surgeon immediately.
BCover the wound with sterile saline-soaked gauze.
CPlace the client in a high Fowler's position.
DApply a sterile abdominal binder to support the wound.
Show the answer and why the others fail
Answer: B. Cover the wound with sterile saline-soaked gauze.
A
While the surgeon must be notified promptly, the nurse's first action is to protect the protruding viscera with sterile saline-soaked gauze to prevent tissue damage and infection.
B — correct
The priority is to protect the exposed bowel from drying and contamination by covering it with sterile saline-soaked dressings, then notify the surgeon immediately.
C
High Fowler's position increases intra-abdominal pressure and tension on the wound; the client should be placed in a low Fowler's or supine position with knees bent to reduce tension.
D
Applying a binder over protruding viscera can cause pressure and further injury; it is not the initial action for evisceration.
TakeawayFor wound evisceration, immediately cover the protruding organs with sterile saline-soaked gauze, then place the client in a low Fowler's position with knees bent, and notify the surgeon.
Surgical nursing · medium
A 55-year-old patient is 8 hours post-abdominal surgery. The patient reports suprapubic discomfort and has not voided since the indwelling catheter was removed 6 hours ago. The nurse palpates a distended bladder. Which action should the nurse take first?
AInsert an indwelling urinary catheter.
BPerform a bladder scan to assess urine volume.
CAdminister the prescribed analgesic for discomfort.
DEncourage the patient to increase oral fluid intake.
Show the answer and why the others fail
Answer: B. Perform a bladder scan to assess urine volume.
A
Inserting a catheter is an invasive procedure that should be performed only after confirming urinary retention through non-invasive assessment, such as a bladder scan.
B — correct
A bladder scan is a non-invasive, evidence-based first step to objectively confirm urinary retention and determine the need for catheterization.
C
While pain management is important, it does not address the underlying problem of suspected urinary retention and may delay necessary intervention.
D
Encouraging fluids may worsen bladder distention if the patient is already retaining urine and unable to void.
TakeawayUse a bladder scan to confirm urinary retention before considering catheterization in postoperative patients.
Surgical nursing · medium
A patient who underwent an open colectomy 48 hours ago reports nausea and abdominal bloating. The nurse notes a firm, distended abdomen and absent bowel sounds. A nasogastric tube is in place, draining minimal bilious fluid, and is connected to low intermittent suction. Which action should the nurse take?
AMaintain nasogastric suction and keep the patient NPO.
BRemove the nasogastric tube and encourage oral fluid intake.
CClamp the nasogastric tube and reassess bowel sounds in 4 hours.
DIrrigate the nasogastric tube with 30 mL of normal saline.
Show the answer and why the others fail
Answer: A. Maintain nasogastric suction and keep the patient NPO.
A — correct
The presentation is consistent with postoperative ileus. Management includes NPO status, nasogastric decompression, and monitoring for return of bowel function (flatus or stool) rather than relying solely on bowel sounds.
B
Removing the NG tube and starting oral intake before bowel function returns would exacerbate distention and nausea, increasing the risk of vomiting and aspiration.
C
Clamping the tube while the patient has distention and absent bowel sounds may worsen nausea and increase the risk of vomiting; return of bowel function should be confirmed by flatus or stool before clamping.
D
Irrigation is not indicated because the tube is draining and patent; unnecessary irrigation can cause discomfort and does not treat the underlying ileus.
TakeawayPostoperative ileus is common after abdominal surgery. Management includes NPO status, nasogastric decompression, and monitoring for return of bowel function (flatus or stool) rather than relying solely on bowel sounds.
Surgical nursing · medium
A 28-year-old patient who underwent open reduction and internal fixation of a tibial fracture 12 hours ago reports severe, unrelieved calf pain despite receiving prescribed morphine. The surgical dressing is not constrictive, and the leg is positioned at heart level. The nurse notes pale toes, capillary refill of 4 seconds, and numbness. What should the nurse do first?
AAdminister another dose of morphine as prescribed.
BElevate the leg on two pillows.
CApply an ice pack to the affected area.
DNotify the surgeon immediately.
Show the answer and why the others fail
Answer: D. Notify the surgeon immediately.
A
Additional opioid analgesia may mask ischemic pain but does not treat the underlying compartment syndrome, which requires prompt surgical intervention.
B
Elevating the leg above heart level reduces arterial perfusion pressure and can exacerbate ischemia. The limb should be kept at heart level, not elevated above it.
C
Cold application causes vasoconstriction, which can further reduce blood flow to an already ischemic limb and worsen compartment syndrome. Ice is contraindicated.
D — correct
The patient's severe unrelieved pain, paresthesia, and perfusion changes are consistent with acute compartment syndrome, a surgical emergency. After ensuring no external compression, the priority is to notify the surgeon for possible fasciotomy.
TakeawaySevere pain unrelieved by analgesia and paresthesia are early signs of compartment syndrome; pallor and delayed capillary refill are late signs. After ensuring no constrictive dressings and maintaining the limb at heart level, immediate surgical notification is essential.
Surgical nursing · medium
A 68-year-old male returns to the surgical unit after a transurethral resection of the prostate (TURP). He has a three-way Foley catheter with continuous bladder irrigation (CBI) infusing normal saline. Two hours postoperatively, the nurse notes the urinary drainage is bright red with visible clots, and the patient reports suprapubic pain and a sensation of bladder fullness. Vital signs are stable. What should the nurse do first?
AIncrease the rate of the continuous bladder irrigation.
BManually irrigate the catheter to remove clots.
CAdminister the prescribed antispasmodic medication.
DNotify the surgeon of the bright red drainage.
Show the answer and why the others fail
Answer: B. Manually irrigate the catheter to remove clots.
A
Increasing the irrigation rate may help prevent further clot formation but will not clear existing clots that are already obstructing the catheter; manual irrigation is required first to restore patency.
B — correct
Suprapubic pain, bladder fullness, and visible clots indicate catheter obstruction, which can lead to bladder distension and increased bleeding; manual irrigation is the priority to clear clots and restore patency.
C
Antispasmodics relieve bladder spasms, but the underlying cause is likely catheter obstruction from clots; giving medication without relieving the obstruction could lead to bladder distension and increased bleeding.
D
While the surgeon should be informed of active bleeding, the immediate nursing priority is to ensure catheter patency; manual irrigation should be attempted first, and the surgeon notified if the obstruction cannot be cleared or bleeding persists.
TakeawayAfter TURP, suprapubic pain, bladder fullness, and visible clots in the drainage suggest catheter obstruction; the nurse's first action is manual irrigation to clear the catheter and prevent complications such as bladder distension and increased bleeding.
Surgical nursing · medium
A 55-year-old male is recovering in the post‑anesthesia care unit after a laparoscopic cholecystectomy. He is using a morphine patient‑controlled analgesia (PCA) pump. Two hours post‑operatively his respirations are 8 breaths per minute, SpO₂ is 90% on room air, and he is difficult to arouse. Which action should the nurse take first?
AIncrease the IV fluid rate to 150 mL/hr to improve circulation.
BCall the surgeon to obtain orders for a blood transfusion.
CAdminister a bolus of IV naloxone 0.04 mg without further assessment.
DImmediately stop the PCA infusion, assess the airway, and encourage deep breathing.
Show the answer and why the others fail
Answer: D. Immediately stop the PCA infusion, assess the airway, and encourage deep breathing.
A
Fluids do not reverse opioid‑induced respiratory depression and will not address the immediate airway risk.
B
Hemorrhage is not indicated by the presented findings; the problem is opioid‑related hypoventilation, not blood loss.
C
Naloxone can cause abrupt withdrawal and pain; the first step is to stop the PCA and reassess before giving an antagonist.
D — correct
The priority is to halt further opioid delivery, evaluate the airway, and promote ventilation before any further interventions.
TakeawayWhen signs of opioid‑induced respiratory depression appear, the nurse’s first action is to discontinue the PCA and assess the airway and ventilation.
Surgical nursing · medium
A 58-year-old man who underwent an open sigmoid colectomy 2 days ago now has a temperature of 38.5°C (101.3°F), heart rate of 112/min, increasing abdominal pain, and his surgical drain is outputting a small amount of bilious fluid. Which action should the nurse take first?
AIncrease the patient’s oral fluid intake to promote hydration.
BAdminister the prescribed analgesic to control the abdominal pain.
CNotify the surgeon promptly about the suspected anastomotic leak.
DEncourage the patient to ambulate to the hallway twice daily.
Show the answer and why the others fail
Answer: C. Notify the surgeon promptly about the suspected anastomotic leak.
A
Oral intake may increase intraluminal pressure and worsen a leak; it is not the immediate priority.
B
Pain control is important, yet masking signs of a leak before surgeon assessment can delay critical treatment.
C — correct
Early surgeon notification is essential for rapid assessment and possible re‑intervention, which can reduce morbidity and mortality.
D
Ambulation is beneficial for recovery but should be delayed until the cause of the leak is evaluated.
TakeawaySuspected anastomotic leak requires immediate surgeon notification for urgent evaluation.
Surgical nursing · medium
A 62‑year‑old man is on postoperative day 3 after an elective left hemicolectomy for cancer. He reports increasing abdominal pain, has a temperature of 38.5°C (101.3°F), a heart rate of 112 bpm, and the surgical drain contains a foul‑smelling, brownish fluid. Which nursing action should be performed first?
AAdminister a bowel‑stimulating laxative to promote gastrointestinal motility.
BIncrease the patient's oral fluids and encourage a high‑protein diet.
CEncourage the patient to ambulate to stimulate bowel function.
DNotify the surgeon immediately about the suspected anastomotic leak.
Show the answer and why the others fail
Answer: D. Notify the surgeon immediately about the suspected anastomotic leak.
A
A laxative could increase intraluminal pressure and worsen the leak.
B
Oral intake may worsen a possible anastomotic leak and is not the priority.
C
Ambulation is beneficial but is not the urgent action when a leak is suspected.
D — correct
Early recognition and rapid surgeon notification are critical to reduce morbidity from a leak.
TakeawaySuspected anastomotic leak requires immediate surgeon notification for prompt intervention.
Surgical nursing · medium
A 58-year-old man is recovering on the surgical unit after an open cholecystectomy. A nasogastric (NG) tube was placed intraoperatively for gastric decompression. The tube is now clamped, and the surgeon has ordered that intermittent suction be started before the patient receives oral fluids. Before initiating suction, the nurse must verify tube placement. Which action is the most appropriate to confirm correct NG tube position at the bedside?
AInsert a second nasogastric tube and compare lengths; matching lengths verify placement.
BPalpate the abdomen to feel the tube tip; a distinct tip indicates correct position.
CListen over the epigastrium while injecting air and listen for a whooshing sound.
DWithdraw a small amount of tube content and test the pH; a value ≤5 confirms gastric placement.
Show the answer and why the others fail
Answer: D. Withdraw a small amount of tube content and test the pH; a value ≤5 confirms gastric placement.
A
Placing a second tube exposes the patient to unnecessary risk and does not confirm the original tube's location.
B
The tube tip cannot be felt through the abdominal wall; palpation does not confirm placement.
C
Auscultation after air insufflation is unreliable and should not be used alone to confirm placement.
D — correct
Gastric aspirate with a pH of 5 or lower is the evidence‑based bedside method to verify NG tube placement before use.
TakeawayBedside verification of NG tube placement is done by aspirating gastric contents and confirming a pH ≤5.
Surgical nursing · medium
A 58‑year‑old man is on postoperative day 2 after a left hemicolectomy performed with a closed‑suction Jackson‑Pratt drain. He reports increasing abdominal pain, has a temperature of 38.2°C (100.8°F), a heart rate of 110/min, and the drain output is now cloudy with a feculent odor. Which nursing action should be taken first?
AApply a warm, moist compress to the incision site to promote circulation and comfort.
BNotify the surgeon immediately about the change in the patient's condition and drain output.
CIncrease the IV fluid rate and encourage the patient to start oral intake as tolerated.
DDocument the findings in the flow sheet and continue routine postoperative monitoring.
Show the answer and why the others fail
Answer: B. Notify the surgeon immediately about the change in the patient's condition and drain output.
A
A warm compress is appropriate for superficial wound care but does not treat a potential intra‑abdominal leak.
B — correct
The combination of fever, tachycardia, abdominal pain, and feculent‑smelling drain output suggests a possible anastomotic leak; rapid surgeon notification is the priority.
C
Increasing fluids and oral intake does not address the suspected anastomotic leak and may worsen peritoneal contamination.
D
Documentation is essential, yet the emergent nature of a suspected leak requires immediate action rather than routine monitoring.
TakeawayEarly recognition and prompt reporting of signs of an anastomotic leak are critical to prevent sepsis and improve surgical outcomes.
Surgical nursing · medium
A 58‑year‑old man underwent a low anterior resection with a loop ileostomy for rectal cancer. Six hours post‑operatively the stoma appears dusky, edematous, and there is no passage of stool. His vital signs are stable, and the abdomen is mildly tender. Which nursing action should be taken first?
AEncourage the patient to increase oral fluid intake to promote output.
BDocument the finding and continue routine postoperative monitoring.
CNotify the surgeon immediately about the possibly ischemic stoma.
DApply a warm, moist compress to the stoma and reassess in 30 minutes.
Show the answer and why the others fail
Answer: C. Notify the surgeon immediately about the possibly ischemic stoma.
A
Increasing fluids will not restore perfusion to an ischemic stoma and delays necessary surgical assessment.
B
Documentation alone is insufficient; the condition requires immediate clinical intervention, not routine monitoring.
C — correct
A dusky, non‑functional stoma suggests impaired blood flow; prompt surgeon notification is critical to prevent necrosis.
D
Warm compresses are for mild edema; they do not address possible stoma ischemia, which is a surgical emergency.
TakeawayAny sign of stoma ischemia (dusky color, edema, no output) warrants immediate surgeon notification.
Surgical nursing · medium
A 68‑year‑old man undergoes elective total knee replacement and receives postoperative epidural analgesia. The surgeon plans to remove the epidural catheter tomorrow morning. The nurse must order low‑molecular‑weight heparin (enoxaparin) for venous thromboembolism prophylaxis. When is the safest time to administer the first dose of enoxaparin in relation to the epidural catheter removal?
AAdminister enoxaparin 2 hours before removal of the epidural catheter.
BAdminister enoxaparin at least 12 hours after the epidural catheter has been removed.
CAdminister enoxaparin 24 hours before the scheduled removal of the epidural catheter.
DAdminister enoxaparin immediately after the epidural catheter is removed, without waiting.
Show the answer and why the others fail
Answer: B. Administer enoxaparin at least 12 hours after the epidural catheter has been removed.
A
Giving anticoagulation before the catheter is removed increases the risk of an epidural hematoma; the dose should be delayed, not advanced.
B — correct
Guidelines recommend waiting ≥12 hours after epidural catheter removal before giving LMWH to minimize spinal hematoma risk.
C
Giving anticoagulation well before removal does not protect against bleeding at the catheter site and may cause unnecessary anticoagulation exposure.
D
Immediate dosing does not allow enough time for hemostasis; the recommended interval is at least 12 hours.
TakeawayAdminister low‑molecular‑weight heparin at least 12 hours after epidural catheter removal to reduce the risk of spinal hematoma.
Surgical nursing · medium
A 58-year-old man undergoes an elective low anterior resection for sigmoid colon cancer. Six hours after surgery he is alert, his temperature is 38.4°C (101.1°F), heart rate is 108/min, blood pressure is 112/68 mmHg, and his abdomen is distended with diffuse tenderness and mild guarding. Which nursing action should be taken first?
ANotify the surgeon immediately about the patient’s fever, tachycardia, and abdominal tenderness.
BEncourage the patient to sit up in a chair and begin ambulation as tolerated.
CGive a rapid 500‑mL bolus of normal saline to treat possible hypovolemia.
DAdminister the ordered intravenous patient-controlled analgesia dose for pain control.
Show the answer and why the others fail
Answer: A. Notify the surgeon immediately about the patient’s fever, tachycardia, and abdominal tenderness.
A — correct
Fever, tachycardia, and abdominal tenderness are early indicators of an anastomotic leak; prompt surgeon notification is essential for emergent evaluation.
B
Early ambulation is beneficial for preventing VTE, but it does not address the acute signs of possible anastomotic leak.
C
Fluid bolus may be needed later, but the priority is to inform the surgeon to assess for a leak; unnecessary fluids could worsen intra‑abdominal edema.
D
Providing analgesia may mask the evolving clinical picture and delay recognition of a surgical complication.
TakeawaySigns of an anastomotic leak (fever, tachycardia, abdominal pain/tenderness) require immediate surgeon notification for timely intervention.
Surgical nursing · medium
A 58‑year‑old man is on postoperative day 3 after a low‑anterior resection for rectal cancer. He reports increasing abdominal pain, has a temperature of 38.7°C (101.7°F), heart rate 112/min, and the surgical drain now shows a large amount of foul‑smelling, feculent fluid. His abdomen is mildly distended and tender. Which nursing action should be taken first?
AIncrease the rate of his intravenous fluids and continue to monitor his vital signs closely.
BNotify the surgeon immediately about the change in the drain output and the patient’s clinical status.
CPlace the patient on NPO status and insert a nasogastric tube for decompression of the abdomen.
DAdminister the prescribed broad‑spectrum intravenous antibiotics and reassess the patient in one hour.
Show the answer and why the others fail
Answer: B. Notify the surgeon immediately about the change in the drain output and the patient’s clinical status.
A
While fluid resuscitation is important, the immediate priority is to alert the surgeon about a possible anastomotic leak.
B — correct
A suspected anastomotic leak is a surgical emergency; rapid notification allows prompt assessment and intervention.
C
NPO and NG decompression are appropriate later steps, but the first action is to inform the surgeon.
D
Antibiotics are part of the treatment but should follow surgeon notification; delaying that step can worsen outcomes.
TakeawayAny sudden change in drain output with systemic signs (fever, tachycardia, abdominal pain) warrants immediate surgeon notification for possible anastomotic leak.
Surgical nursing · medium
A 58-year-old man is on postoperative day 2 after total knee arthroplasty. He suddenly experiences shortness of breath, chest tightness, and a rapid heartbeat. His pulse is 112/min, respirations 28/min, blood pressure 138/84 mmHg, and oxygen saturation is 86% on room air. The surgical unit nurse suspects a pulmonary embolism. Which action should the nurse take first?
AEncourage the patient to ambulate slowly to promote venous return.
BPlace the patient in a high Fowler's position and begin supplemental oxygen therapy.
CObtain a stat D-dimer level to confirm clot formation.
DAdminister a dose of subcutaneous unfractionated heparin as ordered for anticoagulation.
Show the answer and why the others fail
Answer: B. Place the patient in a high Fowler's position and begin supplemental oxygen therapy.
A
Ambulation is a preventive measure; it is unsafe when the patient is critically dyspneic and hypoxic.
B — correct
Improving oxygenation and maximizing lung expansion address the immediate threat to life while other interventions are arranged.
C
A D-dimer is not specific in the postoperative period and obtaining it would delay urgent supportive care.
D
Anticoagulation is essential but should be given after the patient’s airway, breathing, and oxygenation are secured; immediate oxygen therapy takes priority.
TakeawayWhen pulmonary embolism is suspected post‑operatively, the nurse’s priority is to ensure adequate oxygenation and airway support before any diagnostic or therapeutic interventions.
Surgical nursing · medium
A 62‑year‑old man undergoes an open colorectal resection and has a thoracic epidural catheter placed for postoperative analgesia. Four hours after surgery, his vital signs are BP 100/60 mmHg, HR 88 bpm, and SpO2 94% on room air. On assessment, the nurse notes the patient can speak in full sentences but reports a mild tingling sensation in his upper abdomen. Which finding requires the most immediate intervention?
ARespiratory rate measured at 8 breaths per minute with shallow effort.
BWarm, flushed skin over the abdomen but no fever or tachycardia.
CBilateral weakness of both legs while the patient can still wiggle his toes.
DLocalized itching at the epidural insertion site without any erythema or swelling.
Show the answer and why the others fail
Answer: A. Respiratory rate measured at 8 breaths per minute with shallow effort.
A — correct
A respiratory rate <10 breaths/min indicates respiratory depression, which can quickly progress to apnea and must be treated immediately.
B
Warm, flushed skin reflects sympathetic blockade‑induced vasodilation and is not a life‑threatening sign.
C
New bilateral lower‑extremity weakness suggests high spinal spread or epidural hematoma and requires immediate neurologic assessment.
D
Pruritus at the catheter site is a common, benign opioid effect; it can be monitored and treated with antihistamine if needed.
TakeawayA respiratory rate below 10 breaths per minute after epidural analgesia signals respiratory depression or high spinal block and requires rapid intervention to secure the airway and support ventilation.
Surgical nursing · medium
A 58-year-old man is on postoperative day 4 after an open cholecystectomy. His incision shows erythema extending about 2 cm from the edge, is warm to touch, and has serosanguineous drainage. His temperature is 38.3°C (101°F) and he reports mild incision pain. Which nursing action should be taken first?
AApply a warm compress to the incision to promote drainage and healing.
BObtain a wound culture specimen and promptly notify the surgeon.
CRemove the sutures and irrigate the wound with normal saline.
DIncrease the frequency of oral analgesics to control the incision pain.
Show the answer and why the others fail
Answer: B. Obtain a wound culture specimen and promptly notify the surgeon.
A
Warm compresses raise local temperature and can facilitate bacterial growth; they are contraindicated when a surgical site infection is suspected.
B — correct
When infection is suspected, a specimen for microbiologic analysis should be collected and the surgeon notified immediately so that appropriate antimicrobial therapy and wound management can be ordered.
C
Suture removal and wound irrigation are invasive interventions that require a surgeon’s order; the nurse’s initial action is to report the concern, not to perform these procedures independently.
D
Although pain control is important, the erythema, warmth, drainage, and fever indicate a possible surgical site infection; the priority is to report these findings and obtain a culture rather than simply increase analgesics.
TakeawayWhen a surgical site infection is suspected, the nurse should obtain a culture and notify the surgeon before any other interventions.
Surgical nursing · medium
A 52‑year‑old man is recovering on the surgical unit after an uncomplicated laparoscopic cholecystectomy. A low‑pressure Jackson‑Pratt (JP) drain was placed in the right upper quadrant and is attached to its bulb for suction. Six hours post‑op, the nurse notes that the drain output has abruptly stopped, although the collection chamber remains empty. The patient’s vital signs are stable and he reports no new pain. What is the nurse’s priority action?
AFlush the drain with 20 mL of sterile normal saline using a sterile syringe.
BClamp the drain for 30 minutes to allow fluid to accumulate before restarting suction.
CInspect the tubing and bulb for kinks, blockage, or disconnection, and recompress the bulb if needed.
DRemove the drain at the bedside and document the finding as a routine event.
Show the answer and why the others fail
Answer: C. Inspect the tubing and bulb for kinks, blockage, or disconnection, and recompress the bulb if needed.
A
Flushing a closed surgical drain without an order can introduce infection and is not the first assessment step.
B
Clamping can increase intra‑abdominal pressure and mask the underlying problem; it is not the first step when output ceases.
C — correct
The priority is to verify patency and suction function of the closed‑system drain before contacting the surgeon.
D
Drain removal requires a physician’s order; premature removal could allow fluid accumulation.
TakeawayWhen a postoperative surgical drain stops draining, the nurse should first assess the drain system for kinks, blockage, or loss of suction before notifying the surgeon.
Surgical nursing · medium
A 68‑year‑old woman underwent a total hip arthroplasty on the left side. On postoperative day 1 she asks to sit on the edge of the bed to read a book. Which nursing action is most appropriate to prevent hip dislocation?
AInstruct the patient to cross her legs while seated to improve circulation and comfort during recovery.
BAssist the patient to sit on the side of the bed with hips and knees flexed to 90 degrees, keeping both feet flat on the floor.
CAllow the patient to sit on the edge of the bed with her knees extended and hips flexed to 120 degrees, then let her swing her legs.
DEncourage the patient to stand and bear full weight on the operative limb immediately after surgery, with assistance if needed.
Show the answer and why the others fail
Answer: B. Assist the patient to sit on the side of the bed with hips and knees flexed to 90 degrees, keeping both feet flat on the floor.
A
Crossing the legs causes hip adduction and internal rotation, both of which are prohibited because they can dislocate the new joint.
B — correct
Hip precautions after arthroplasty require flexion ≤90°, knees flexed, and feet flat on the floor to maintain safe alignment and prevent dislocation.
C
Hip flexion greater than 90° and knee extension place the prosthetic joint at high risk for anterior dislocation; this action is contraindicated.
D
Immediate full weight‑bearing is often restricted; premature loading can stress the repair and increase the chance of dislocation.
TakeawayAfter total hip arthroplasty, maintain hip flexion ≤90°, avoid adduction and internal rotation, and keep feet flat on the floor to prevent prosthetic dislocation.
Surgical nursing · medium
A 58-year-old man undergoes an open inguinal hernia repair under general anesthesia. In the post‑anesthesia care unit, he reports mild shortness of breath. Auscultation reveals decreased breath sounds at both lung bases, and his SpO₂ is 94% on room air. Which nursing action is most appropriate to prevent further postoperative respiratory compromise?
AAdminister an intravenous diuretic to reduce possible fluid overload and improve lung expansion.
BInitiate incentive spirometry every hour, ensuring the patient is comfortable and pain is adequately controlled.
CEncourage deep breathing and coughing exercises while ensuring the patient’s pain is well controlled.
DApply high‑flow oxygen via a non‑rebreather mask to increase oxygen saturation.
Show the answer and why the others fail
Answer: C. Encourage deep breathing and coughing exercises while ensuring the patient’s pain is well controlled.
A
Diuretics are indicated for volume overload, not for early postoperative hypoventilation caused by pain and reduced inspiratory effort.
B
When pain is managed, incentive spirometry offers no additional advantage over simple deep‑breathing exercises, making it a less essential first intervention.
C — correct
Deep breathing and coughing with adequate analgesia promote maximal lung expansion, improve ventilation, and prevent atelectasis—the primary mechanism behind the patient’s dyspnea.
D
Supplemental oxygen temporarily raises SpO₂ but does not correct shallow breathing or prevent atelectasis, so it does not address the underlying problem.
TakeawayBoth deep‑breathing/coughing exercises and incentive spirometry can help prevent postoperative atelectasis when combined with adequate pain control; encouraging deep breathing with analgesia is the primary evidence‑based intervention.