Nokea
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed to avoid wrong-site surgery? Select all that apply.
- A. Ask the surgeon preoperatively to mark with a permanent marker the correct knee for the surgical site.
- B. Verbally ask the client to state his name, surgical site, and procedure.
- C. Verify the correct client with the correct operative site by medical records and radiographic diagnostic reports.
- D. Call a 'time-out' in the operating room to have the surgeon verify the correct knee before making the incision.
- E. Show the client an anatomic model of the surgery site.
Correct Answer: A,B,C,D
Rationale: To prevent wrong-site surgery, the surgeon marks the site (A), the client verifies identity and procedure (B), records are checked (C), and a time-out confirms the site (D). Showing a model (E) is educational but not a standard safety measure.
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A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
- A. Remove the necklace during transport.
- B. Tape the necklace securely to the client's chest.
- C. Insist the client comply with policy.
- D. Notify the surgeon to cancel the procedure.
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
A client has vertigo. Which of the following actions would be most appropriate for the nursing diagnosis of Risk for injury related to altered immobility and gait disturbances? Select all that apply.
- A. The client assumes safe position when dizzy.
- B. The client experiences no falls.
- C. The client performs vestibular/balance exercises.
- D. The client demonstrates family involvement.
- E. The client keeps head still when dizzy.
Correct Answer: A,B,C,E
Rationale: Appropriate actions include assuming a safe position (e.g., sitting or lying down), preventing falls, performing vestibular exercises to improve balance, and keeping the head still during vertigo to minimize symptoms and reduce injury risk.
The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate?
- A. Placing a pillow in the axilla so the arm is away from the body.
- B. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow.
- C. Immobilizing the extremity in a sling.
- D. Positioning a hand cone in the hand so the fingers are barely flexed.
- E. Keeping the arm at the side using a pillow.
Correct Answer: A,D
Rationale: Placing a pillow in the axilla (A) prevents adduction contractures, and a hand cone (D) maintains slight finger flexion to avoid claw-hand deformity. A sling or keeping the arm at the side may promote contractures, and elevating the hand above the elbow is less critical.
Which pediatric surgery client should not play with a balloon?
- A. A child having her 15th laser surgery for a hemangioma.
- B. A child having a tonsillectomy.
- C. A child having an inguinal hernia repair.
- D. A child having an orchiopexy.
Correct Answer: B
Rationale: A child post-tonsillectomy should avoid balloons, as blowing or playing with them can increase intraoral pressure, risking bleeding or disruption of the surgical site.
The nurse develops a teaching plan for a client scheduled for a spinal fusion. Which of the following should the nurse expect to include?
- A. The client typically experiences more pain at the donor site than at the fusion site.
- B. The surgeon will apply a simple gauze dressing to the donor site.
- C. Neurovascular checks are unnecessary if the fibula is the donor site.
- D. The client's level of activity restriction is determined by the amount of pain.
Correct Answer: A
Rationale: The donor site (e.g., iliac crest) often causes more pain than the fusion site due to tissue trauma.