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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Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?
- A. Calcium 9.2 mg/dL.
- B. Bleeding time two (2) minutes.
- C. Hemoglobin 15 g/dL.
- D. Potassium 2.4 mEq/L.
Correct Answer: D
Rationale: Hypokalemia (2.4 mEq/L, normal 3.5–5.0) risks arrhythmias during anesthesia, requiring immediate intervention. Normal calcium, bleeding time, and hemoglobin are safe.
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.
Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?
- A. Alteration in comfort.
- B. Disuse syndrome.
- C. Risk for injury.
- D. Altered gas exchange.
Correct Answer: C
Rationale: Risk for injury (e.g., from positioning, equipment) is a primary intraoperative concern, per NANDA-I. Comfort, disuse, and gas exchange are more postoperative or anesthesia-related.
Which statement should the nurse identify as the expected outcome for a client experiencing acute pain?
- A. The client will have decreased use of medication.
- B. The client will participate in self-care activities.
- C. The client will use relaxation techniques.
- D. The client will repeat instructions about medications.
Correct Answer: B
Rationale: Participating in self-care indicates effective pain control, enabling function, the primary outcome. Medication reduction, relaxation, and instruction repetition are secondary.
The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication?
- A. Alteration in comfort.
- B. Risk for depressed respiratory pattern.
- C. Potential for infection.
- D. Fluid and electrolyte imbalance.
Correct Answer: B
Rationale: Narcan reverses opioid-induced respiratory depression, but risk persists, requiring monitoring. Comfort, infection, and fluid imbalance are unrelated to Narcan.