Nokea
The client in the surgical holding area tells the nurse 'I am so scared. I have never had surgery before.' Which statement would be the most appropriate response?
- A. Why are you afraid of the surgery?
- B. This is the best hospital in the city.
- C. Does having surgery make you afraid?
- D. There is no reason to be afraid.
Correct Answer: C
Rationale: Reflecting the client’s fear validates feelings, encouraging discussion. Asking 'why,' boasting about the hospital, or dismissing fear is less therapeutic.
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The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse?
- A. The 4-year-old client who had a tonsillectomy and is able to swallow fluids.
- B. The 74-year-old client with a repair of the left hip who is unable to ambulate.
- C. The 24-year-old client who had an uncomplicated appendectomy the previous day.
- D. The 80-year-old client with small bowel obstruction and congestive heart failure.
Correct Answer: D
Rationale: The 80-year-old with small bowel obstruction and CHF has complex needs (fluid balance, cardiac monitoring), requiring an experienced nurse. Tonsillectomy, hip repair, and appendectomy are less complex.
Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale (pointing to faces) is age-appropriate for a 4-year-old, per pediatric pain assessment guidelines. Simple words are vague, numeric scales are for older children, and scheduled medication is not assessment.
The nurse is preparing a client for surgery. Which intervention should the nurse implement first?
- A. Check the permit for the spouse's signature.
- B. Take and document intake and output.
- C. Administer the 'on call' sedative.
- D. Complete the preoperative checklist.
Correct Answer: D
Rationale: The preoperative checklist ensures all safety measures (e.g., consent, NPO, allergies) are verified, the first step. Spouse signature, I&O, and sedatives follow checklist completion.
The nurse is planning the care of the surgical client having procedural sedation. Which intervention has highest priority?
- A. Assess the client's respiratory status.
- B. Monitor the client's urinary output.
- C. Take a 12-lead ECG prior to injection.
- D. Attempt to keep the client focused.
Correct Answer: A
Rationale: Procedural sedation risks respiratory depression; assessing respiratory status is critical for safety. Urinary output, ECG, and focus are secondary.
The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement?
- A. Insert an indwelling catheter.
- B. Increase the intravenous fluid rate.
- C. Assist the client to stand to void.
- D. Encourage the client to increase fluids.
Correct Answer: C
Rationale: Standing to void facilitates urination by using gravity, a non-invasive first step. Catheterization, IV fluids, and oral fluids are more invasive or secondary.