Nokea
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.
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Splinting an incision is an intervention to accomplish what goal?
- A. Provide extra support during coughing
- B. Reduce the need for analgesia
- C. Prevent shallow breathing
- D. Explain that some pain is normal
Correct Answer: A
Rationale: Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.
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.
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.
A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?
- A. Explain the rationale for giving the medicine now
- B. Leave the room and come back in 15 minutes
- C. Provide holistic client care and come back later
- D. Tell the client you must start the medication now
Correct Answer: A
Rationale: The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative.
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.