Nokea
A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?
- A. Allow the client to walk to the bathroom
- B. Assist the client to the bathroom
- C. Give the client a bedpan or urinal to use
- D. Insert a urinary catheter now instead of waiting
Correct Answer: C
Rationale: Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after sedation due to safety concerns. Providing a bedpan or urinal is the safest option. The client may or may not need a urinary catheter, depending on the surgical procedure.
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A nurse working in the preoperative holding area performs which functions to ensure client safety?
- A. Allow small sips of plain water
- B. Check that consent forms are appropriately completed
- C. Ensure the client has an armband on
- D. Have the client help mark the surgical site
- E. Allow the client to use the toilet before giving sedation
Correct Answer: B,C,D,E
Rationale: Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client's identity, having the client assist in marking the surgical site if applicable, and allowing the client to use the toilet prior to sedation are important safety measures. The preoperative client should be NPO, so water should not be provided.
A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?
- A. It helps prevent ulcers from the stress of the surgery
- B. It reduces stomach acid to prevent aspiration
- C. Since you don't have ulcers, I will have to ask
- D. The physician prescribed this medication for you
Correct Answer: B
Rationale: Ranitidine (Zantac) is given preoperatively to reduce gastric acid production, which lowers the risk of aspiration during surgery. This is the most accurate explanation. Preventing ulcers is not the primary purpose in this context, and the other options do not provide a clear rationale.
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
- A. Assess the client for anxiety
- B. Break the information into smaller bits
- C. Give the client written information
- D. Request the provider to repeat the information
Correct Answer: A
Rationale: Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.
The Surgical Care Improvement Project (SCIP) includes which core measures?
- A. Preventing infection
- B. Preventing serious cardiac events
- C. Preventing thrombembolic events
- D. Improving surgical technique
- E. Enhancing postoperative recovery
Correct Answer: B,C,E
Rationale: The SCIP project includes core measures to prevent infection, serious cardiac events, and thrombembolic events such as deep vein thrombosis.
A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical claim?
- A. Allergy to bee and wasp sting
- B. History of lactose intolerance
- C. No previous experience with surgery
- D. Use of herbal supplements
Correct Answer: D
Rationale: Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. A lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety.