Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a surgery unit. Which task would be most appropriate to delegate to the UAP?
- A. Explain to the client how to cough and deep breathe.
- B. Discuss preoperative plans with the client and family.
- C. Determine the ability of the caregivers to provide postoperative care.
- D. Assist the client to take a povidone-iodine (Betadine) shower.
Correct Answer: D
Rationale: Assisting with a Betadine shower is a non-invasive task within UAP scope. Teaching, discussing plans, and assessing caregivers require nursing judgment.
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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.
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.
Which nursing intervention has the highest priority when preparing the client for a surgical procedure?
- A. Pad the client's elbows and knees.
- B. Apply soft restraint straps to the extremities.
- C. Prepare the client's incision site.
- D. Document the temperature of the room.
Correct Answer: C
Rationale: Preparing the incision site ensures asepsis, reducing infection risk, the highest priority. Padding, restraints, and room temperature are secondary.
Which statement would be an expected outcome for the postoperative client who had general anesthesia?
- A. The client will be able to sit in the chair for 30 minutes.
- B. The client will have a pulse oximetry reading of 97% on room air.
- C. The client will have a urine output of 30 mL per hour.
- D. The client will be able to distinguish sharp from dull sensations.
Correct Answer: B
Rationale: A pulse oximetry of 97% on room air indicates adequate oxygenation post-general anesthesia, a key outcome. Sitting, urine output, and sensation are secondary or unrelated.