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The nurse clears the PCA pump and discovers the client has used only a small amount of medication during the shift. Which intervention should the nurse implement?
- A. Determine why the client is not using the PCA pump.
- B. Document the amount and take no action.
- C. Chart the client is not having pain.
- D. Contact the HCP and request oral medication.
Correct Answer: A
Rationale: Determining why the client underuses the PCA (e.g., misunderstanding, side effects) ensures effective pain management. Documentation alone, assuming no pain, or changing medication is premature.
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The client one (1) day postoperative develops an elevated temperature. Which intervention would have priority for the client?
- A. Encourage the client to deep breathe and cough every hour.
- B. Encourage the client to drink 200 mL of water every shift.
- C. Monitor the client's wound for drainage every eight (8) hours.
- D. Assess the urine output for color and clarity every four (4) hours.
Correct Answer: A
Rationale: Fever post-surgery often stems from atelectasis; deep breathing and coughing prevent respiratory complications, the priority. Hydration, wound monitoring, and urine assessment are secondary.
Which client assessment data are priority for the postanesthesia care nurse?
- A. Bowel sounds.
- B. Vital signs.
- C. IV fluid rate.
- D. Surgical site.
Correct Answer: B
Rationale: Vital signs are the priority in PACU to monitor stability per ABCs. Bowel sounds, IV rate, and surgical site are secondary.
The nurse is completing the preoperative checklist. Which laboratory value should be reported to the health-care provider immediately?
- A. Hemoglobin 13.1 g/dL.
- B. Glucose 60 mg/dL.
- C. White blood cells 6 (x10³/mm³).
- D. Potassium 3.8 mEq/L.
Correct Answer: B
Rationale: Glucose of 60 mg/dL indicates hypoglycemia, risking perioperative complications, requiring immediate HCP notification. Normal hemoglobin, WBC, and potassium are safe.
Which intervention has priority for the nurse in the surgical holding area?
- A. Verify the surgical checklist.
- B. Prepare the client's surgical site.
- C. Assist the client to the bathroom.
- D. Restrain the client on the surgery table.
Correct Answer: A
Rationale: Verifying the surgical checklist ensures safety (e.g., site, consent), the priority in the holding area. Site prep, bathroom assistance, and restraints are secondary or intraoperative.
The nurse is assessing a client in the day surgery unit who states, 'I am really afraid of having this surgery. I'm afraid of what they will find.' Which statement would be the most therapeutic response by the nurse?
- A. Don't worry about your surgery. It is safe.
- B. Tell me why you're worried about your surgery.
- C. Tell me about your fears of having this surgery.
- D. I understand how you feel. Surgery is frightening.
Correct Answer: C
Rationale: Asking about fears encourages the client to express concerns, fostering therapeutic communication. Reassurance, asking 'why,' or assuming feelings are less empathetic.