Perioperative nursing — the pre-op, intra-op, and post-op care around surgery — is heavily tested on the NCLEX. Work through these 10 practice questions on informed consent, the surgical time-out, malignant hyperthermia, PACU priorities, and post-op complications like hemorrhage and evisceration, each with a full rationale that explains why every option is right or wrong.
Perioperative Nursing: Consent, Safety & Post-Op Priorities
Perioperative nursing spans three phases: pre-operative, intra-operative, and post-operative. On the NCLEX, the highest-yield pre-op concepts are informed consent and safety verification. Remember the roles: the surgeon or provider explains the procedure, its risks, benefits, and alternatives; the nurse witnesses the client's signature and confirms the consent is voluntary and that the client understands. If the client cannot describe the surgery in their own words, stop and notify the surgeon before proceeding. Consent must be signed before any sedating pre-op medication. Minors (unless emancipated or otherwise permitted by state law) and clients who are not decisional need a legal surrogate, but a true life-threatening emergency may proceed without consent. Pre-op nursing verifies NPO status, allergies, labs, and the signed consent; removes jewelry, dentures, prosthetics, contacts, and nail polish; confirms the site is marked; completes the checklist; and teaches turning, coughing, deep breathing, incentive spirometry, incision splinting, and early ambulation.
Intra-operatively, the Universal Protocol time-out verifies the correct client, correct site, and correct procedure before incision, and the surgical team performs sponge, instrument, and needle counts. Malignant hyperthermia is the marquee emergency: an inherited (autosomal dominant) reaction to volatile anesthetics and succinylcholine. The earliest signs are a rising end-tidal CO2 and tachycardia; a rapidly climbing temperature is a late hallmark. Priority care is to stop the triggering agent and give dantrolene, with active cooling and supportive measures.
In the PACU, always work the ABCs first: airway patency and return of the gag reflex (aspiration risk), then breathing, then circulation and bleeding, then level of consciousness and pain. Position an unconscious or sedated client side-lying to protect the airway. Watch for post-op complications: atelectasis (early), pneumonia, DVT/PE, paralytic ileus, urinary retention, and hemorrhage progressing to hypovolemic shock (tachycardia with hypotension; check the dressing and underneath the client). Distinguish dehiscence (wound edges separate) from evisceration (organs protrude) — evisceration is a surgical emergency: cover the viscera with a sterile saline-moistened dressing, position low-Fowler with knees flexed, keep the client NPO, stay with them, and call the surgeon.
Perioperative Nursing NCLEX Practice Questions
Question 1 · Informed Consent
A client scheduled for a laparoscopic cholecystectomy has signed the surgical consent form. When the nurse asks the client to describe the planned surgery, the client says, "I'm not really sure what they're taking out or why." What is the nurse's best action?
- A Reinforce the surgeon's teaching and proceed with pre-op preparation
- B Notify the surgeon that the client cannot describe the procedure
- C Ask a family member to explain the surgery to the client
- D Document that the consent is valid because the client already signed it
Show answer & rationale
Correct answer: B
Informed consent requires that the client understands the procedure, its risks, benefits, and alternatives. Explaining the surgery is the surgeon's legal responsibility; the nurse witnesses the signature and confirms the client understands and is consenting voluntarily. When the client cannot describe the procedure, understanding is in question, so the consent may not be valid. The correct action is to notify the surgeon before proceeding so the provider can re-explain and re-confirm consent. Reinforcing teaching and proceeding is wrong because clarifying the procedure itself (not just reinforcing) is the surgeon's duty, and proceeding on invalid consent is unsafe. Asking a family member to explain is inappropriate; the surgeon, not family, provides procedure education, and the family member may be inaccurate. Documenting the consent as valid simply because it is signed ignores that a signature without understanding does not constitute informed consent. Clinical pearl: a signature is necessary but not sufficient. If the client cannot state in their own words what is being done, STOP and call the surgeon. Remember the roles with 'surgeon explains, nurse witnesses.' Consent must also be obtained before any sedating pre-op medication is given, because a sedated client cannot give informed consent.
Question 2 · Informed Consent Timing
A nurse is preparing a client for surgery. The pre-op orders include IV midazolam for sedation, and the surgical consent form has not yet been signed. What is the nurse's priority action?
- A Administer the midazolam so the client is calm when signing
- B Explain the procedure and its risks to the client yourself, have the client sign, then give the midazolam
- C Ensure the consent is signed before administering the midazolam
- D Hold all pre-op medications until the client reaches the OR
Show answer & rationale
Correct answer: C
Informed consent must be obtained while the client is fully alert and able to understand and make a voluntary decision. Sedatives such as midazolam impair judgment and comprehension, so consent obtained after sedation is legally invalid. The priority is to ensure the consent is signed before administering the sedating medication. Giving the midazolam first, whether to calm the client or otherwise, invalidates any consent obtained afterward. Explaining the procedure and its risks yourself and then having the client sign is incorrect because the surgeon is responsible for explaining the procedure and obtaining informed consent; the nurse’s role is to witness the signature and verify that understood, voluntary consent is complete before any sedation is given. Holding all pre-op medications until the OR is unnecessary and could disrupt the surgical plan (e.g., prophylactic antibiotics, ordered as needed medications) — the issue is specifically the timing of sedation relative to consent, not withholding everything. Clinical pearl: 'Consent before sedation.' If a client has already received a sedating drug and consent is not yet signed, notify the surgeon; the surgery may need to be delayed until the client is alert enough to consent, unless it is a life-threatening emergency in which case emergency consent rules apply.
Question 3 · Pre-Op Checklist
A nurse is completing the pre-operative checklist for a client going to the OR in one hour. Which actions should the nurse take? Select all that apply.
- A Document allergies and confirm the allergy band is in place
- B Give the client a full breakfast to maintain energy for surgery
- C Verify that the surgical consent form is signed and witnessed
- D Remove the client's dentures, jewelry, and nail polish
- E Confirm the client's NPO status and time of last intake
- F Verify that the surgical site is marked
Show answer & rationale
Correct answer: A, C, D, E, F
The pre-op checklist confirms readiness and safety. Verifying the signed and witnessed consent is essential — surgery cannot proceed without valid consent. Confirming NPO status prevents aspiration under anesthesia; the nurse documents the time of last food and fluid intake. Removing dentures, jewelry, and nail polish is required: dentures and loose items threaten the airway and can be lost or cause pressure injury, metal jewelry poses a burn risk with electrocautery, and nail polish can interfere with pulse oximetry readings (also remove prosthetics, contacts, and hearing aids per facility policy). Verifying the surgical site is marked supports the Universal Protocol and prevents wrong-site surgery. Documenting allergies and confirming the allergy band prevents intra-op and post-op medication reactions. Giving the client a full breakfast is incorrect and dangerous — it violates NPO status and dramatically increases aspiration risk, and would cause the surgery to be canceled or delayed. Clinical pearl: think 'consent, NPO, allergies, labs, remove-and-mark' as the core pre-op sweep. When in doubt about any missing item, do not send the client to the OR until it is resolved.
Question 4 · Surgical Time-Out
Just before the surgeon makes the incision, the surgical team pauses to conduct the time-out. Which elements must be verified during the time-out as part of the Universal Protocol?
- A Correct client, correct surgical site, and correct procedure
- B The client's insurance coverage and billing information
- C The number of visitors allowed in the waiting room
- D The client's preferred discharge date and transportation plan
Show answer & rationale
Correct answer: A
The time-out is a mandatory pause conducted by the entire surgical team immediately before incision, and it is the final safeguard of the Universal Protocol against wrong-site, wrong-procedure, and wrong-person surgery. The team must verify the correct client (using two identifiers), the correct surgical site (matching the marked site), and the correct procedure, along with confirmation that the consent, relevant imaging, and needed equipment are available. Insurance coverage and billing are administrative concerns handled well before surgery and have no place in the clinical safety time-out. The number of visitors allowed in the waiting room is irrelevant to surgical safety. The client's discharge date and transportation, while part of overall discharge planning, are not verified during the pre-incision time-out. Clinical pearl: remember the three 'correct's — correct client, correct site, correct procedure. Everyone stops what they are doing and actively participates; if any team member has a concern, the incision does not proceed until it is resolved. The time-out complements, but does not replace, site marking and the surgical safety checklist (including sponge, instrument, and needle counts) that guard against retained foreign objects.
Question 5 · Malignant Hyperthermia
Shortly after induction with a volatile anesthetic and succinylcholine, a client develops a sharply rising end-tidal CO2, tachycardia, and muscle rigidity. Malignant hyperthermia is suspected. What is the priority intervention?
- A Apply cooling blankets and wait to see if the temperature rises
- B Increase the depth of anesthesia to relax the muscles
- C Administer an antipyretic such as acetaminophen
- D Stop the triggering anesthetic agent and administer dantrolene
Show answer & rationale
Correct answer: D
Malignant hyperthermia is a life-threatening, inherited (autosomal dominant) hypermetabolic reaction to volatile anesthetics and the depolarizing paralytic succinylcholine. The earliest signs are an unexplained rise in end-tidal CO2 and tachycardia, often with masseter/muscle rigidity; a rapidly rising temperature is a LATE hallmark, so waiting for fever to confirm the diagnosis wastes critical time. The priority is to immediately stop the triggering agent and administer dantrolene, the specific antidote that halts the abnormal calcium release in skeletal muscle. Active cooling and supportive care (treating hyperkalemia, acidosis, and dysrhythmias) follow, but only cooling and 'waiting to see' fails to stop the underlying reaction and is inadequate. An antipyretic such as acetaminophen does not work because the heat is generated by uncontrolled muscle metabolism, not a hypothalamic set-point change — antipyretics are ineffective in MH. Increasing anesthetic depth with the same volatile agent would worsen the reaction because the anesthetic is the trigger. Clinical pearl: 'Stop the gas, push dantrolene, cool the client.' Rising end-tidal CO2 is the earliest and most sensitive warning; a personal or family history of anesthesia reactions or unexplained peri-operative death should raise suspicion pre-operatively.
Question 6 · PACU Priorities
A nurse receives a client in the PACU who is drowsy and not yet fully awake after general anesthesia. Which nursing action is the priority?
- A Assess the client's pain level and administer ordered analgesics
- B Check the surgical dressing for bleeding
- C Orient the client to person, place, and time
- D Ensure a patent airway and assess for return of the gag reflex
Show answer & rationale
Correct answer: D
In the PACU the nurse follows the ABCs, so airway is always the first priority. A client who is not fully awake after general anesthesia is at high risk for airway obstruction (from the tongue or secretions) and aspiration because protective reflexes, including the gag reflex, may not have fully returned. Ensuring a patent airway and assessing for the gag reflex — and positioning the client side-lying if not fully awake — takes precedence over everything else. Assessing and treating pain is important but comes after airway, breathing, and circulation are secured; giving opioids to a sedated client with an unprotected airway could worsen respiratory depression. Checking the dressing addresses circulation/bleeding, which is assessed after airway and breathing. Orienting the client relates to level of consciousness, which follows the ABCs. Clinical pearl: the PACU priority sequence is airway/gag reflex, then breathing, then circulation/bleeding, then LOC and pain. Position an unconscious or sedated post-op client side-lying (recovery position) to let secretions drain and keep the airway open until they are awake enough to protect it themselves.
Question 7 · Evisceration Management
Four days post-op from an abdominal surgery, a client coughs forcefully and calls the nurse. The nurse finds loops of bowel protruding through the open incision. Which action should the nurse take first?
- A Gently push the bowel back into the abdominal cavity
- B Cover the exposed bowel with a sterile saline-moistened dressing
- C Place the client in high-Fowler position and offer oral fluids
- D Leave the wound open to air and obtain vital signs
Show answer & rationale
Correct answer: B
Protruding abdominal organs indicate evisceration, a surgical emergency. The immediate priority is to protect the exposed viscera by covering them with a sterile dressing moistened with sterile normal saline; this keeps the tissue moist, reduces the risk of drying and infection, and preserves organ viability until the client returns to surgery. The nurse should also position the client in low-Fowler with knees slightly flexed to reduce tension on the wound, keep the client NPO, stay with the client, and notify the surgeon immediately. Pushing the bowel back into the abdomen is never done — it can damage the organs and introduce infection. Placing the client in high-Fowler and offering oral fluids is wrong on two counts: the upright/flexed hip position increases abdominal tension and organ protrusion is worsened, and giving fluids violates the NPO status needed for emergency surgery. Leaving the wound open to air allows the tissue to dry out and become necrotic and does not address the emergency. Clinical pearl: 'moist, sterile, low-Fowler, NPO, stay and call.' Distinguish dehiscence (wound edges separate) from evisceration (organs protrude); both often follow a sudden increase in intra-abdominal pressure such as coughing or straining, so teach clients to splint the incision.
Question 8 · Post-Op Hemorrhage
Two hours after surgery, a client's blood pressure has dropped from 122/78 to 88/54 mm Hg and the heart rate has risen to 122/min. The client is restless and the dressing appears dry. What should the nurse do first?
- A Check under the client and the surgical dressing for pooling blood
- B Administer the ordered as-needed opioid for restlessness
- C Document the findings and recheck the vital signs in one hour
- D Encourage the client to use the incentive spirometer
Show answer & rationale
Correct answer: A
A rising heart rate with a falling blood pressure and restlessness is the classic picture of hypovolemic shock from post-op hemorrhage; the drop in blood pressure means compensation is already failing. A dry-appearing dressing can be falsely reassuring because blood follows gravity and pools underneath the client where it is not visible from the top of the dressing. The priority action is to inspect both the dressing and underneath the client (back, flanks, and bed linens) to detect concealed bleeding, then notify the surgeon and prepare for fluid resuscitation. Documenting and rechecking in an hour delays care during an emergency and could be fatal. Administering an opioid is dangerous — restlessness here signals hypoperfusion and hypoxia, not pain, and an opioid would drop the blood pressure further and mask the deterioration. Using the incentive spirometer addresses atelectasis prevention and is irrelevant to acute hemorrhage. Clinical pearl: in the bleeding post-op client, tachycardia usually appears before hypotension, and restlessness/anxiety is an early sign of shock. Always 'check the dressing AND under the client' — assess reinforcement, mark and time drainage borders, and trend vital signs frequently.
Question 9 · Post-Op Complication Prevention
A nurse is planning care to prevent post-operative complications for a client on the first day after abdominal surgery. Which interventions should the nurse include? Select all that apply.
- A Keep the client on strict bed rest until the sutures are removed
- B Teach the client to splint the incision when coughing and deep breathing
- C Encourage use of the incentive spirometer every 1-2 hours while awake
- D Maintain the client flat and discourage turning to protect the incision
- E Assess bowel sounds and keep the client NPO until peristalsis returns
- F Apply sequential compression devices and promote early ambulation
Show answer & rationale
Correct answer: B, C, E, F
Post-op care targets the common complications. Incentive spirometry every 1-2 hours while awake, along with coughing and deep breathing, expands the alveoli and prevents atelectasis and pneumonia — the earliest and most common respiratory complications. Sequential compression devices plus early ambulation promote venous return and prevent DVT and its feared complication, pulmonary embolism. Teaching the client to splint the incision (with a pillow or hands) supports the wound during coughing and mobility, encourages effective airway clearance, and reduces the risk of dehiscence/evisceration. Assessing bowel sounds and keeping the client NPO until peristalsis returns is appropriate because anesthesia and handling of the bowel cause paralytic ileus; feeding before return of function risks distention, nausea, and vomiting. Strict bed rest until sutures are removed is incorrect and harmful — immobility drives DVT, atelectasis, pneumonia, ileus, and pressure injury; early mobilization is a cornerstone of recovery. Keeping the client flat and discouraging turning is also wrong; frequent repositioning and turning improve ventilation, circulation, and skin integrity. Clinical pearl: 'move, breathe, and splint.' Early ambulation is one of the single best interventions to prevent multiple post-op complications at once.
Question 10 · Pre-Op Teaching
During pre-operative teaching for a client scheduled for abdominal surgery, which instructions should the nurse include to prepare the client for recovery? Select all that apply.
- A "You should avoid coughing completely so you don't disturb the incision."
- B "We'll help you get up and walk early, often the day of or day after surgery."
- C "Support your incision with a pillow when you cough or move."
- D "You will be taught to take slow, deep breaths and use an incentive spirometer."
- E "Try to lie still and avoid moving your legs to protect the surgical site."
- F "Let us know about your pain so we can keep it managed with your pain plan."
Show answer & rationale
Correct answer: B, C, D, F
Effective pre-op teaching prepares the client to participate in preventing complications. Teaching slow, deep breathing and incentive spirometer use trains the client to expand the lungs and prevent atelectasis and pneumonia. Splinting the incision with a pillow when coughing or moving reduces pain and wound tension and helps the client cough effectively without fear of dehiscence. Explaining early ambulation sets expectations that the client will be helped up soon after surgery, which prevents DVT/PE, ileus, and pulmonary complications. Encouraging the client to report pain so it can be managed on the pain plan supports comfort, mobility, and effective deep breathing (uncontrolled pain leads to shallow breathing and immobility). Telling the client to lie still and avoid moving the legs is wrong — leg movement and ambulation prevent venous stasis and DVT, so immobility is discouraged. Telling the client to avoid coughing completely is also incorrect; controlled coughing (with splinting) clears secretions and prevents pneumonia. Clinical pearl: pre-op teaching that covers turn, cough, deep-breathe, incentive spirometer, splint, ambulate, and pain plan gives the client the tools to actively prevent the most common post-op problems — and clients who understand the 'why' are far more likely to comply.
Want more practice questions? Create a free NCLEX Key account — NCLEX-style questions with a full rationale on every answer. No credit card.
Start practicing free →
Perioperative Nursing FAQ
Who is responsible for obtaining informed consent for surgery?
The surgeon or provider performing the procedure is legally responsible for explaining the procedure, its risks, benefits, and alternatives and for obtaining informed consent. The nurse's role is to witness the client's signature and to confirm the consent is voluntary and that the client understands. If the client cannot describe the surgery in their own words, the nurse should stop and notify the surgeon before proceeding rather than reinforcing or re-explaining the procedure themselves.
What are the earliest signs of malignant hyperthermia?
The earliest and most sensitive signs are an unexplained, rapidly rising end-tidal CO2 and tachycardia, often accompanied by muscle rigidity, after exposure to a volatile anesthetic or succinylcholine. A rapidly rising body temperature is a late hallmark, so you should never wait for fever to act. Priority treatment is to stop the triggering agent, give dantrolene, and begin active cooling and supportive care.
What is the difference between wound dehiscence and evisceration?
Dehiscence is separation of the surgical wound edges without organ protrusion. Evisceration is more severe — abdominal organs protrude through the open wound, and it is a surgical emergency. For evisceration, cover the exposed viscera with a sterile saline-moistened dressing, position the client low-Fowler with knees slightly flexed, keep them NPO, stay with them, and notify the surgeon immediately. Never attempt to push the organs back in.
What is the nurse's first priority when caring for a client in the PACU?
Airway comes first. Follow the ABCs: ensure a patent airway and assess for return of the gag reflex, since a client who is not fully awake is at risk for airway obstruction and aspiration. Position a sedated or unconscious client side-lying to protect the airway. After airway and breathing are secured, assess circulation and bleeding, then level of consciousness and pain.