The client’s postoperative orders state “diet as tolerated.” The client has been NPO. The nurse will advance the client’s diet to clear liquids based on which assessment? Select all that apply

Does not complain of nausea or vomiting

Pain level is maintained at a rating of 2–3 out of 10

States passing flatus

Ambulates with minimal assistance

Expresses feeling “hungry”

Answer and Explanation

Correct Answer : A,C

When advancing a postoperative patient from NPO to clear liquids, the nurse checks for signs the GI tract and protective reflexes have returned: no nausea/vomiting, presence of bowel sounds or passage of flatus, intact gag reflex, and stable vital signs.

Rationale for correct answer:

1. Does not complain of nausea or vomiting: Absence of nausea or vomiting reduces aspiration risk and indicates the patient is more likely to tolerate oral intake.

3. States passing flatus: Passing flatus is an objective sign of returning bowel motility (ileus resolving) and supports advancing diet to clear liquids.

Rationale for incorrect answers:

2. Pain level is maintained at a rating of 2-3 out of 10: Good pain control is desirable, but a moderate pain score alone doesn’t guarantee GI tract readiness or safe swallowing.

4. Ambulates with minimal assistance: Ambulation shows overall stability and helps GI motility, but it is not by itself a direct indicator that the GI tract can tolerate oral intake.

5. Expresses feeling “hungry”: Subjective and not sufficient. Hunger does not confirm bowel function or absence of aspiration risk and should not be the sole reason to advance diet.

Take home points:

Advance to clear liquids when objective signs of GI function and tolerance are present.
Subjective cues (feeling hungry) and general stability (ambulating) are helpful context but do not replace primary clinical indicators of GI readiness.

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Correct Answer is D

Explanation

After surgery, immobility increases the risk of venous stasis, leading to DVT and emboli. Preventive measures such as leg exercises, early ambulation, elastic stockings, and sequential compression devices are essential parts of postoperative nursing care.

Rationale for correct answer:

4. Increase venous return: Surgery and immobility increase the risk of venous stasis, which predisposes patients to deep vein thrombosis and pulmonary embolism. Leg exercises contract the muscles of the lower extremities, which act as a pump to improve circulation and venous return.

Rationale for incorrect answers:

1. Promote respiratory function: While respiratory function is an important concern postoperatively, leg exercises specifically target circulation in the lower extremities, not the lungs.

2. Maintain functional abilities: Early ambulation and mobility exercises are used to maintain muscle tone and prevent deconditioning.

3. Provide diversional activities: Leg exercises are not intended as recreation. While they may distract briefly, the primary purpose is physiological, not psychological.

Take home points:

Leg exercises after surgery prevent venous stasis and thrombus formation by promoting blood flow and venous return.
Patient education is critical - when patients understand why they need to do leg exercises, they are more likely to comply, reducing the risk of DVT and pulmonary embolism.

A. Respiratory system B. Circulatory system C. Digestive system D. Nervous system

Correct Answer is A

Explanation

Thoracic incisions limit chest wall excursion and make coughing painful, so patients breathe more shallowly and cannot clear secretions effectively. This predisposes them to atelectasis and postoperative pneumonia.

Rationale for correct answer:

1. Respiratory system: A thoracic incision (thoracotomy, thoracic surgery) impairs chest wall movement, causes pain with deep breathing and coughing, and often leads to shallow respirations and ineffective cough - all of which increase risk for atelectasis and pneumonia.

Rationale for incorrect answers:

2. Circulatory system: Major thoracic surgery can affect hemodynamics in some cases, but the most immediate and common postoperative complications after a thoracic incision are pulmonary.

3. Digestive system: Digestive complications are more commonly related to abdominal surgery. A thoracic incision does not directly impair bowel motility the way abdominal manipulation does.

4. Nervous system: Neurologic complications are not the principal concern specifically from a thoracic incision; while pain and anesthesia affect the nervous system, the primary system at direct risk is respiratory.

Take home points:

After thoracic surgery prioritize respiratory assessment and interventions- incentive spirometry, splinting, analgesia, early mobilization.
Pain control that permits deep breathing and coughing is essential to prevent atelectasis and pneumonia.

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The client’s postoperative orders state “diet as tolerated.” The client has been NPO. The nurse will advance the client’s diet to clear liquids based on which assessment? Select all that apply

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Naxlex Comprehensive Predictor Exams

The nurse is explaining the rationale for performing leg exercises after surgery. Which reason would the nurse include in the explanation?

Correct Answer is D

Explanation

Mr. Moreno has had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that he will have a higher risk for postoperative complications involving which body system?

Correct Answer is A

Explanation

The client’s postoperative orders state “diet as tolerated.” The client has been NPO. The nurse will advance the client’s diet to clear liquids based on which assessment? Select all that apply

Which of the following surgical patients is at a greater risk for alterations in body image?

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Gas pains are a common postoperative discomfort. Which of the following nursing actions implemented in the plan of care would be most likely to relieve gas pains?

An 85-year-old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following place the patient at risk during surgery? Select all that apply

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