Nokea
The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage?
- A. The 16-year-old client in the dorsal recumbent position having an appendectomy.
- B. The 68-year-old client in the Trendelenburg position having a cholecystectomy.
- C. The 45-year-old client in the reverse Trendelenburg position having a biopsy.
- D. The 22-year-old client in the lateral position having a nephrectomy.
Correct Answer: D
Rationale: The lateral position risks brachial plexus or peroneal nerve damage due to pressure on dependent limbs, especially during prolonged surgery like nephrectomy. Other positions have lower nerve risks.
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Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Complete the preoperative checklist.
- B. Assess the client's preoperative vital signs.
- C. Teach the client about coughing and deep breathing.
- D. Assist the client to remove clothing and jewelry.
Correct Answer: D
Rationale: Removing clothing and jewelry is a non-invasive task within UAP scope. Checklist completion, vital signs, and teaching require nursing judgment.
The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first?
- A. Apply antiembolism hose to the client.
- B. Attach the drain to 20 cm suction.
- C. Assess the client's vital signs.
- D. Listen to the report from the anesthesiologist.
Correct Answer: C
Rationale: Assessing vital signs establishes a baseline post-PACU, per ABCs. Antiembolism hose, drain attachment, and anesthesiologist report follow.
The nurse is receiving a client from the postanesthesia care unit (PACU). Which interventions should the nurse implement? Select all that apply.
- A. Ambulate the client to the bathroom to void.
- B. Take the client's vital signs to compare with PACU data.
- C. Monitor all lines into and out of the client's body.
- D. Assess the client's surgical site.
- E. Push the client's PCA button to treat for pain during movement.
Correct Answer: B,C,D
Rationale: Vital signs establish a baseline, line monitoring ensures patency, and surgical site assessment detects complications. Ambulation is premature, and nurses cannot push PCA buttons.
Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?
- A. Loss of sensation at the lumbar (L5) dermatome.
- B. Absence of the client's posterior tibial pulse.
- C. The client has a respiratory rate of eight (8).
- D. The blood pressure is within 20% of the client's baseline.
Correct Answer: C
Rationale: A respiratory rate of 8 suggests respiratory depression, a serious spinal anesthesia complication. L5 numbness is expected, absent pulse suggests vascular issues, and stable BP is normal.
The unlicensed assistive personnel (UAP) can be overheard talking loudly to the scrub technologist discussing a problem which occurred during one (1) of the surgeries. Which intervention should the nurse in the surgical holding area with a female client implement?
- A. Close the curtains around the client's stretcher.
- B. Instruct the UAP and scrub tech to stop the discussion.
- C. Tell the surgeon on the case what the nurse overheard.
- D. Inform the client the discussion was not about her surgeon.
Correct Answer: B
Rationale: Instructing the UAP and tech to stop protects patient privacy and reduces anxiety, per HIPAA. Curtains, informing the surgeon, or reassuring the client are less direct.