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The circulating nurse notes a discrepancy in the needle count. What intervention should the nurse implement first?
- A. Inform the other members of the surgical team about the problem.
- B. Assume the original count was wrong and change the record.
- C. Call the radiology department to perform a portable x-ray.
- D. Complete an occurrence report and notify the risk manager.
Correct Answer: A
Rationale: Informing the team prompts a recount and investigation, the first step to prevent retained needles. Assuming errors, ordering x-rays, or reporting are premature.
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The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first?
- A. Assess the client's breath sounds.
- B. Apply oxygen via nasal cannula.
- C. Take the client's blood pressure.
- D. Monitor the pulse oximeter reading.
Correct Answer: A
Rationale: Assessing breath sounds ensures airway patency and ventilation, the priority post-OR per ABCs. Oxygen, BP, and pulse oximetry follow airway assessment.
Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?
- A. Change the dressing over the surgical site.
- B. Teach the client how to perform incentive spirometry.
- C. Empty and record the amount of drainage in the JP drain.
- D. Auscultate the bowel sounds in all four (4) quadrants.
Correct Answer: C
Rationale: Emptying and recording JP drain output is a technical task within UAP scope. Dressing changes, teaching, and auscultation require nursing judgment.
The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply.
- A. Give a back rub to the client to relieve stiffness.
- B. Apply ice packs to the axillary and groin areas.
- C. Prepare an ice slush for the client to drink.
- D. Prepare to administer dantrolene, a smooth-muscle relaxant.
- E. Reposition the client on a warming blanket.
Correct Answer: B,D
Rationale: Tachycardia, hyperthermia, and muscle stiffness suggest malignant hyperthermia; ice packs cool the body, and dantrolene reverses the condition. Back rubs, ice slush, and warming blankets are inappropriate.
The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed?
- A. I will be glad when this is over so I can go home today.
- B. I will not be able to eat or drink anything prior to my surgery.
- C. I can practice relaxing by listening to my favorite music.
- D. I will need to get up and walk as soon as possible.
Correct Answer: A
Rationale: Emergency appendectomy requires postoperative recovery, typically 1–2 days in hospital, so expecting to go home today indicates misunderstanding. NPO status, relaxation, and early ambulation are correct.
The client has undergone an abdominal perineal resection of the colon for colon cancer with a left lower quadrant colostomy. Which interventions should the nurse implement? Select all that apply.
- A. Assess the stoma for color every four (4) hours and prn.
- B. Encourage the client to turn, cough, and deep breathe every two (2) hours.
- C. Maintain the head of the bed 30 to 40 degrees elevated at all times.
- D. Auscultate for bowel sounds every four (4) hours.
- E. Administer pain medications sparingly to prevent addiction.
Correct Answer: A,B,D
Rationale: Stoma assessment monitors viability, coughing/deep breathing prevents atelectasis, and bowel sound checks assess GI function. HOB elevation is case-specific, and sparing pain medication risks undertreatment.