Nokea
The client in the surgery holding area identifies the left arm as the correct surgical site, but the operative permit designates surgery to be performed on the right arm. Which interventions should the nurse implement? Select all that apply.
- A. Review the client's chart.
- B. Notify the surgeon.
- C. Immediately call a 'time-out.'
- D. Correct the surgical permit.
- E. Request the client mark the left arm.
Correct Answer: A,B,C
Rationale: Reviewing the chart verifies the correct site, notifying the surgeon addresses the discrepancy, and calling a time-out ensures team confirmation. Correcting the permit or marking the wrong site is unsafe.
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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 task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Complete the preoperative checklist.
- B. Assess the client's preoperative vital signs.
- C. Teach the client about coughing and deep breathing.
- D. Assist the client to remove clothing and jewelry.
Correct Answer: D
Rationale: Removing clothing and jewelry is a non-invasive task within UAP scope. Checklist completion, vital signs, and teaching require nursing judgment.
The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first?
- A. Apply antiembolism hose to the client.
- B. Attach the drain to 20 cm suction.
- C. Assess the client's vital signs.
- D. Listen to the report from the anesthesiologist.
Correct Answer: C
Rationale: Assessing vital signs establishes a baseline post-PACU, per ABCs. Antiembolism hose, drain attachment, and anesthesiologist report follow.
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.
The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement?
- A. Place the sponge back where it was.
- B. Tell the technician not to waste supplies.
- C. Do nothing because this is the correct procedure.
- D. Take the sponge out of the room immediately.
Correct Answer: C
Rationale: Removing a potentially contaminated sponge from the sterile field edge is correct to maintain asepsis. Replacing, criticizing, or removing it immediately is incorrect.