Nokea
The client is in the lithotomy position during surgery. Which nursing intervention should be implemented to decrease a complication from the positioning?
- A. Increase the intravenous fluids.
- B. Lower one leg at a time.
- C. Raise the foot of the stretcher.
- D. Administer epinephrine, a vasopressor.
Correct Answer: B
Rationale: Lowering legs sequentially prevents rapid blood pressure drops from venous pooling, reducing circulatory complications in lithotomy. Fluids, stretcher elevation, and epinephrine are unrelated.
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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.
The client has undergone an abdominal perineal resection of the colon for colon cancer with a left lower quadrant colostomy. Which interventions should the nurse implement? Select all that apply.
- A. Assess the stoma for color every four (4) hours and prn.
- B. Encourage the client to turn, cough, and deep breathe every two (2) hours.
- C. Maintain the head of the bed 30 to 40 degrees elevated at all times.
- D. Auscultate for bowel sounds every four (4) hours.
- E. Administer pain medications sparingly to prevent addiction.
Correct Answer: A,B,D
Rationale: Stoma assessment monitors viability, coughing/deep breathing prevents atelectasis, and bowel sound checks assess GI function. HOB elevation is case-specific, and sparing pain medication risks undertreatment.
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 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.
The nurse is completing the preoperative checklist on a client going to surgery. Which information should the nurse report to the surgeon?
- A. The client understands the purpose of the surgery.
- B. The client stopped taking aspirin three (3) weeks ago.
- C. The client uses the oral supplements licorice and garlic.
- D. The client has mild levels of preoperative anxiety.
Correct Answer: C
Rationale: Licorice and garlic may increase bleeding risk or interact with anesthesia, requiring surgeon notification. Understanding, aspirin cessation, and mild anxiety are expected or safe.