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The circulating nurse observes the surgeon tossing a bloody gauze sponge onto the sterile field. Which action should the circulating nurse implement first?
- A. Include the sponge in the sponge count.
- B. Obtain a new sterile instrument pack.
- C. Tell the surgical technologist about the sponge.
- D. Throw the sponge in the sterile trashcan.
Correct Answer: C
Rationale: Telling the technologist ensures the contaminated sponge is removed from the sterile field, maintaining asepsis. Counting, new instruments, or trashing are secondary or incorrect.
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Which action by the client indicates to the nurse preoperative teaching has been effective?
- A. The client demonstrates how to use the incentive spirometer device.
- B. The client demonstrates the use of the patient-controlled analgesia pump.
- C. The client can name two (2) anesthesia agents used during surgery.
- D. The client ambulates down the hall to the nurse's station each hour.
Correct Answer: A
Rationale: Using the incentive spirometer correctly prevents atelectasis, a key preoperative teaching goal. PCA use is postoperative, naming agents is unnecessary, and hourly ambulation is excessive.
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 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.
The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement?
- A. Administer pain medication as soon as the time frame allows.
- B. Use nonpharmacological methods to replace medications.
- C. Use cryotherapy after heat therapy because it works faster.
- D. Instruct family members to administer medication with the PCA.
Correct Answer: A
Rationale: Administering pain medication PRN within time frames ensures timely relief, per pain management standards. Nonpharmacological methods supplement, cryotherapy timing varies, and family PCA use is unsafe.
The nurse is conducting an interview with a 75-year-old client admitted with acute pain. Which question would have priority when assisting with pain management?
- A. Have you ever had difficulty getting your pain controlled?
- B. What types of surgery have you had in the last 10 years?
- C. Have you ever been addicted to narcotics?
- D. Do you have a list of your prescription medications?
Correct Answer: A
Rationale: Asking about past pain control identifies effective strategies or barriers, guiding management. Surgical history, addiction, and medication lists are secondary.