Nokea
The client is in the lithotomy position during surgery. Which nursing intervention should be implemented to decrease a complication from the positioning?
- A. Increase the intravenous fluids.
- B. Lower one leg at a time.
- C. Raise the foot of the stretcher.
- D. Administer epinephrine, a vasopressor.
Correct Answer: B
Rationale: Lowering legs sequentially prevents rapid blood pressure drops from venous pooling, reducing circulatory complications in lithotomy. Fluids, stretcher elevation, and epinephrine are unrelated.
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The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply.
- A. Give a back rub to the client to relieve stiffness.
- B. Apply ice packs to the axillary and groin areas.
- C. Prepare an ice slush for the client to drink.
- D. Prepare to administer dantrolene, a smooth-muscle relaxant.
- E. Reposition the client on a warming blanket.
Correct Answer: B,D
Rationale: Tachycardia, hyperthermia, and muscle stiffness suggest malignant hyperthermia; ice packs cool the body, and dantrolene reverses the condition. Back rubs, ice slush, and warming blankets are inappropriate.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a surgery unit. Which task would be most appropriate to delegate to the UAP?
- A. Explain to the client how to cough and deep breathe.
- B. Discuss preoperative plans with the client and family.
- C. Determine the ability of the caregivers to provide postoperative care.
- D. Assist the client to take a povidone-iodine (Betadine) shower.
Correct Answer: D
Rationale: Assisting with a Betadine shower is a non-invasive task within UAP scope. Teaching, discussing plans, and assessing caregivers require nursing judgment.
The client diagnosed with appendicitis has undergone an appendectomy. At two (2) hours postoperative, the nurse takes the vital signs and notes T 102.6°F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority.
- A. Increase the IV rate.
- B. Notify the health-care provider.
- C. Elevate the foot of the bed.
- D. Check the abdominal dressing.
- E. Determine if the IV antibiotics have been administered.
Correct Answer: C,A,B,D,E
Rationale: 1) Elevate foot of bed (Trendelenburg for hypotension); 2) Notify HCP (fever, tachycardia, hypotension suggest sepsis); 3) Increase IV rate (bolus for hypovolemia); 4) Check dressing (assess bleeding); 5) Confirm antibiotics (treat infection).
The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply.
- A. The client has loose, decayed teeth.
- B. The client is experiencing anxiety.
- C. The client smokes two (2) packs of cigarettes a day.
- D. The client has had a chest x-ray which does not show infiltrates.
- E. The client reports using herbs.
Correct Answer: A,C,E
Rationale: Loose teeth risk airway obstruction, smoking affects respiratory function and anesthesia, and herbs (e.g., ginseng) may interact with anesthesia, requiring anesthesiologist notification. Anxiety is common, and clear x-rays are reassuring.
Which nursing intervention is priority for the client experiencing acute pain?
- A. Assess the client's verbal and nonverbal behavior.
- B. Wait for the client to request pain medication.
- C. Administer the pain medication on a scheduled basis.
- D. Teach the client to use only imagery every hour for the pain.
Correct Answer: A
Rationale: Assessing verbal and nonverbal behavior determines pain severity and guides treatment, the priority. Waiting, scheduled dosing, or imagery alone delays or limits care.