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The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome?
- A. The client has no injuries from the OR equipment.
- B. The client has no postoperative infection.
- C. The client has stable vital signs during surgery.
- D. The client recovers from anesthesia.
Correct Answer: A
Rationale: The circulating nurse’s role focuses on preventing equipment-related injuries (e.g., burns, pressure sores) intraoperatively. Infection, vital signs, and recovery are broader concerns.
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Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale (pointing to faces) is age-appropriate for a 4-year-old, per pediatric pain assessment guidelines. Simple words are vague, numeric scales are for older children, and scheduled medication is not assessment.
The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first?
- A. Notify the surgeon of the client's status.
- B. Continue giving enemas until clear.
- C. Increase the client's IV fluid rate.
- D. Obtain STAT serum electrolytes.
Correct Answer: A
Rationale: Notifying the surgeon ensures guidance on proceeding, as unclear returns may indicate obstruction or inadequate prep, risking complications. More enemas, IV fluids, or electrolytes are secondary.
The unlicensed assistive personnel (UAP) reports the vital signs for a first-day postoperative client as T 100.8°F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement?
- A. Administer the antibiotic earlier than scheduled.
- B. Change the dressing over the wound.
- C. Have the client turn, cough, and deep breathe every two (2) hours.
- D. Encourage the client to ambulate in the hall.
Correct Answer: C
Rationale: A low-grade fever (100.8°F) and tachypnea (R 24) suggest atelectasis; turning, coughing, and deep breathing prevent respiratory complications. Antibiotics, dressing changes, and ambulation are secondary.
Which violation of surgical asepsis would require immediate intervention by the circulating nurse?
- A. Surgical supplies were cleaned and sterilized prior to the case.
- B. The circulating nurse is wearing a long-sleeved sterile gown.
- C. Masks covering the mouth and nose are being worn by the surgical team.
- D. The scrub nurse setting up the sterile field is wearing artificial nails.
Correct Answer: D
Rationale: Artificial nails harbor bacteria, violating asepsis and risking infection, requiring immediate intervention. Sterilized supplies, masks, and long-sleeved gowns (if non-sterile role) are appropriate.
Which statement should the nurse identify as the expected outcome for a client experiencing acute pain?
- A. The client will have decreased use of medication.
- B. The client will participate in self-care activities.
- C. The client will use relaxation techniques.
- D. The client will repeat instructions about medications.
Correct Answer: B
Rationale: Participating in self-care indicates effective pain control, enabling function, the primary outcome. Medication reduction, relaxation, and instruction repetition are secondary.