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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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Which nursing intervention is priority for the client experiencing acute pain?
- A. Assess the client's verbal and nonverbal behavior.
- B. Wait for the client to request pain medication.
- C. Administer the pain medication on a scheduled basis.
- D. Teach the client to use only imagery every hour for the pain.
Correct Answer: A
Rationale: Assessing verbal and nonverbal behavior determines pain severity and guides treatment, the priority. Waiting, scheduled dosing, or imagery alone delays or limits care.
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.
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 is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply.
- A. The client has loose, decayed teeth.
- B. The client is experiencing anxiety.
- C. The client smokes two (2) packs of cigarettes a day.
- D. The client has had a chest x-ray which does not show infiltrates.
- E. The client reports using herbs.
Correct Answer: A,C,E
Rationale: Loose teeth risk airway obstruction, smoking affects respiratory function and anesthesia, and herbs (e.g., ginseng) may interact with anesthesia, requiring anesthesiologist notification. Anxiety is common, and clear x-rays are reassuring.
Which nursing intervention has the highest priority when preparing the client for a surgical procedure?
- A. Pad the client's elbows and knees.
- B. Apply soft restraint straps to the extremities.
- C. Prepare the client's incision site.
- D. Document the temperature of the room.
Correct Answer: C
Rationale: Preparing the incision site ensures asepsis, reducing infection risk, the highest priority. Padding, restraints, and room temperature are secondary.