Nokea
The three (3)-day postoperative client is complaining of unrelieved pain at the incision site one (1) hour after the administration of narcotic pain medication. Which action should the nurse implement first?
- A. Check the MAR for another medication to administer.
- B. Teach the client to use guided imagery to relieve the pain.
- C. Assess the client for complications.
- D. Elevate the head of the client's bed.
Correct Answer: C
Rationale: Unrelieved pain post-narcotic may indicate complications (e.g., infection, hematoma), requiring assessment first. Additional medication, imagery, or HOB elevation follow.
You may also like to solve these questions
The nurse is assessing a client in the day surgery unit who states, 'I am really afraid of having this surgery. I'm afraid of what they will find.' Which statement would be the most therapeutic response by the nurse?
- A. Don't worry about your surgery. It is safe.
- B. Tell me why you're worried about your surgery.
- C. Tell me about your fears of having this surgery.
- D. I understand how you feel. Surgery is frightening.
Correct Answer: C
Rationale: Asking about fears encourages the client to express concerns, fostering therapeutic communication. Reassurance, asking 'why,' or assuming feelings are less empathetic.
Which client outcome would the nurse identify for the preoperative client?
- A. The client's abnormal laboratory data will be reported to the anesthesiologist.
- B. The client will not have any postoperative complications for the first 24 hours.
- C. The client will demonstrate the use of a pillow to splint while deep breathing.
- D. The client will complete an advance directive before having the surgery.
Correct Answer: C
Rationale: Demonstrating pillow splinting for deep breathing prepares the client to prevent atelectasis, a measurable preoperative outcome. Lab reporting, complication-free periods, and advance directives are not client actions.
Which client assessment data are priority for the postanesthesia care nurse?
- A. Bowel sounds.
- B. Vital signs.
- C. IV fluid rate.
- D. Surgical site.
Correct Answer: B
Rationale: Vital signs are the priority in PACU to monitor stability per ABCs. Bowel sounds, IV rate, and surgical site are secondary.
Which intervention has priority for the nurse in the surgical holding area?
- A. Verify the surgical checklist.
- B. Prepare the client's surgical site.
- C. Assist the client to the bathroom.
- D. Restrain the client on the surgery table.
Correct Answer: A
Rationale: Verifying the surgical checklist ensures safety (e.g., site, consent), the priority in the holding area. Site prep, bathroom assistance, and restraints are secondary or intraoperative.
The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement?
- A. Prepare ice packs and mix dantrolene sodium.
- B. Request the defibrillator be brought into the OR.
- C. Draw a PTT and prepare a heparin drip.
- D. Obtain finger stick blood glucose immediately.
Correct Answer: B
Rationale: Tachycardia and hypotension suggest shock or arrhythmia, requiring a defibrillator for potential cardioversion. Dantrolene is for malignant hyperthermia, heparin for clotting, and glucose is unrelated.