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The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement?
- A. Place the sponge back where it was.
- B. Tell the technician not to waste supplies.
- C. Do nothing because this is the correct procedure.
- D. Take the sponge out of the room immediately.
Correct Answer: C
Rationale: Removing a potentially contaminated sponge from the sterile field edge is correct to maintain asepsis. Replacing, criticizing, or removing it immediately is incorrect.
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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 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.
Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected?
- A. Urine output was 160 mL in the past eight (8) hours.
- B. Paralysis and paresthesia of the right leg.
- C. T 99.0°F, P 98, R 20, and BP 100/60.
- D. Lungs are clear bilaterally in all lobes.
Correct Answer: D
Rationale: Clear lungs indicate no respiratory complications, expected post-hip replacement. Low urine output (20 mL/hr), paralysis/paresthesia, and mild hypotension suggest complications.
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 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.