Nokea
The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage?
- A. The 16-year-old client in the dorsal recumbent position having an appendectomy.
- B. The 68-year-old client in the Trendelenburg position having a cholecystectomy.
- C. The 45-year-old client in the reverse Trendelenburg position having a biopsy.
- D. The 22-year-old client in the lateral position having a nephrectomy.
Correct Answer: D
Rationale: The lateral position risks brachial plexus or peroneal nerve damage due to pressure on dependent limbs, especially during prolonged surgery like nephrectomy. Other positions have lower nerve risks.
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The nurse is receiving a client from the postanesthesia care unit (PACU). Which interventions should the nurse implement? Select all that apply.
- A. Ambulate the client to the bathroom to void.
- B. Take the client's vital signs to compare with PACU data.
- C. Monitor all lines into and out of the client's body.
- D. Assess the client's surgical site.
- E. Push the client's PCA button to treat for pain during movement.
Correct Answer: B,C,D
Rationale: Vital signs establish a baseline, line monitoring ensures patency, and surgical site assessment detects complications. Ambulation is premature, and nurses cannot push PCA buttons.
The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement?
- A. Administer pain medication as soon as the time frame allows.
- B. Use nonpharmacological methods to replace medications.
- C. Use cryotherapy after heat therapy because it works faster.
- D. Instruct family members to administer medication with the PCA.
Correct Answer: A
Rationale: Administering pain medication PRN within time frames ensures timely relief, per pain management standards. Nonpharmacological methods supplement, cryotherapy timing varies, and family PCA use is unsafe.
The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching?
- A. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth.
- B. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion.
- C. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume.
- D. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.
Correct Answer: D
Rationale: Getting out of bed upright risks hip dislocation post-hip replacement; log-rolling is correct. Diaphragmatic breathing, foot exercises, and spirometry are appropriate.
Which statement explains the nurse's responsibility when obtaining informed consent for the client undergoing a surgical procedure?
- A. The nurse should provide detailed information about the procedure.
- B. The nurse should inform the client of any legal consultation needed.
- C. The nurse should write a list of the risks for postoperative complications.
- D. The nurse should ensure the client is voluntarily giving consent.
Correct Answer: D
Rationale: The nurse ensures voluntary consent, verifying understanding and no coercion, per ethical standards. Detailed information, legal consultation, and risk lists are the HCP’s role.
The nursing manager is making assignments for the OR. Which case should the manager assign to the inexperienced nurse?
- A. The client having open-heart surgery.
- B. The client having a biopsy of the breast.
- C. The client having laser eye surgery.
- D. The client having a laparoscopic knee repair.
Correct Answer: B
Rationale: Breast biopsy is a straightforward, low-risk procedure suitable for an inexperienced nurse. Open-heart, laser eye, and laparoscopic surgeries require advanced skills.