Nokea
The nurse identifies the nursing diagnosis 'risk for injury related to positioning' for the client in the operating room. Which nursing intervention should the nurse implement?
- A. Avoid using the cautery unit which does not have a biomedical tag on it.
- B. Carefully pad the client's elbows before covering the client with a blanket.
- C. Apply a warming pad on the OR table before placing the client on the table.
- D. Check the chart for any prescription or over-the-counter medication use.
Correct Answer: B
Rationale: Padding elbows prevents pressure injuries during positioning, addressing the diagnosis. Cautery, warming pads, and medication checks are unrelated to positioning.
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The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed?
- A. I will be glad when this is over so I can go home today.
- B. I will not be able to eat or drink anything prior to my surgery.
- C. I can practice relaxing by listening to my favorite music.
- D. I will need to get up and walk as soon as possible.
Correct Answer: A
Rationale: Emergency appendectomy requires postoperative recovery, typically 1–2 days in hospital, so expecting to go home today indicates misunderstanding. NPO status, relaxation, and early ambulation are correct.
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 postoperative client complains of hearing a 'popping sound' and feeling 'something opening' when ambulating in the room. Which intervention should the nurse implement first?
- A. Notify the surgeon the client has had an evisceration.
- B. Contact the surgery department to prepare for emergency surgery.
- C. Assess the operative site and cover the site with a moistened dressing.
- D. Explain this is a common feeling and tell the client to continue with activity.
Correct Answer: C
Rationale: A popping sound and opening sensation suggest dehiscence or evisceration; assessing and covering with a moist dressing stabilizes the site, the first step. Notification and surgery prep follow, and dismissing the symptom is unsafe.
Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain?
- A. Monitor the client's vital signs.
- B. Verify the time of the last dose.
- C. Check for the client's allergies.
- D. Discuss the pain with the client.
Correct Answer: C
Rationale: Checking allergies prevents adverse reactions, the highest safety priority. Vital signs, timing, and pain discussion follow.
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.