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The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome?
- A. The client has no injuries from the OR equipment.
- B. The client has no postoperative infection.
- C. The client has stable vital signs during surgery.
- D. The client recovers from anesthesia.
Correct Answer: A
Rationale: The circulating nurse’s role focuses on preventing equipment-related injuries (e.g., burns, pressure sores) intraoperatively. Infection, vital signs, and recovery are broader concerns.
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Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?
- A. Alteration in comfort.
- B. Disuse syndrome.
- C. Risk for injury.
- D. Altered gas exchange.
Correct Answer: C
Rationale: Risk for injury (e.g., from positioning, equipment) is a primary intraoperative concern, per NANDA-I. Comfort, disuse, and gas exchange are more postoperative or anesthesia-related.
The client received naloxone (Narcan), an opioid antagonist, in the postanesthesia care unit. Which nursing intervention should the nurse include in the care plan?
- A. Measure the client's intake and output hourly.
- B. Administer sleep medications at night.
- C. Encourage the client to verbalize feelings.
- D. Monitor respirations every 15 to 30 minutes.
Correct Answer: D
Rationale: Narcan reverses opioid-induced respiratory depression, requiring frequent respiratory monitoring to detect recurrence. I&O, sleep aids, and verbalization are secondary.
The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first?
- A. Notify the surgeon of the client's status.
- B. Continue giving enemas until clear.
- C. Increase the client's IV fluid rate.
- D. Obtain STAT serum electrolytes.
Correct Answer: A
Rationale: Notifying the surgeon ensures guidance on proceeding, as unclear returns may indicate obstruction or inadequate prep, risking complications. More enemas, IV fluids, or electrolytes are secondary.
Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain?
- A. Ineffective coping.
- B. Potential for injury.
- C. Alteration in comfort.
- D. Altered sensory input.
Correct Answer: C
Rationale: Alteration in comfort directly addresses acute pain’s impact, per NANDA-I. Coping, injury, and sensory input are secondary or unrelated.
Which statement should the nurse identify as the expected outcome for a client experiencing acute pain?
- A. The client will have decreased use of medication.
- B. The client will participate in self-care activities.
- C. The client will use relaxation techniques.
- D. The client will repeat instructions about medications.
Correct Answer: B
Rationale: Participating in self-care indicates effective pain control, enabling function, the primary outcome. Medication reduction, relaxation, and instruction repetition are secondary.