Nokea
The client received naloxone (Narcan), an opioid antagonist, in the postanesthesia care unit. Which nursing intervention should the nurse include in the care plan?
- A. Measure the client's intake and output hourly.
- B. Administer sleep medications at night.
- C. Encourage the client to verbalize feelings.
- D. Monitor respirations every 15 to 30 minutes.
Correct Answer: D
Rationale: Narcan reverses opioid-induced respiratory depression, requiring frequent respiratory monitoring to detect recurrence. I&O, sleep aids, and verbalization are secondary.
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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.
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.
Which violation of surgical asepsis would require immediate intervention by the circulating nurse?
- A. Surgical supplies were cleaned and sterilized prior to the case.
- B. The circulating nurse is wearing a long-sleeved sterile gown.
- C. Masks covering the mouth and nose are being worn by the surgical team.
- D. The scrub nurse setting up the sterile field is wearing artificial nails.
Correct Answer: D
Rationale: Artificial nails harbor bacteria, violating asepsis and risking infection, requiring immediate intervention. Sterilized supplies, masks, and long-sleeved gowns (if non-sterile role) are appropriate.
The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome?
- A. The client has no injuries from the OR equipment.
- B. The client has no postoperative infection.
- C. The client has stable vital signs during surgery.
- D. The client recovers from anesthesia.
Correct Answer: A
Rationale: The circulating nurse’s role focuses on preventing equipment-related injuries (e.g., burns, pressure sores) intraoperatively. Infection, vital signs, and recovery are broader concerns.
Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective?
- A. I will take my temperature each week and report any elevation.
- B. I will not need any pain medication when I go home.
- C. I will take all of my antibiotics until they are gone.
- D. I will not take a shower until my three (3)-month checkup.
Correct Answer: C
Rationale: Completing antibiotics prevents infection, a key teaching point. Weekly temperature checks are excessive, pain medication is often needed, and showering is allowed sooner.