Nokea
The nurse is administering an opioid narcotic to the client. Which interventions should the nurse implement for client safety? Select all that apply.
- A. Compare the hospital number on the MAR to the client's bracelet.
- B. Have a witness verify the wasted portion of the narcotic.
- C. Assess the client's vital signs prior to administration.
- D. Determine if the client has any allergies to medications.
- E. Clarify all pain medication orders with the health-care provider.
Correct Answer: A,B,C,D
Rationale: Verifying ID, witnessing waste, checking vital signs, and confirming allergies ensure opioid safety. Clarifying all orders is unnecessary unless unclear.
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The nurse is completing a preoperative assessment on a male client who states, 'I am allergic to codeine.' Which intervention should the nurse implement first?
- A. Apply an allergy bracelet on the client's wrist.
- B. Label the client's allergies on the front of the chart.
- C. Ask the client what happens when he takes the codeine.
- D. Document the allergy on the medication administration record.
Correct Answer: C
Rationale: Asking about the reaction verifies the allergy type (e.g., anaphylaxis vs. nausea), guiding safe care. Bracelet, labeling, and documentation follow verification.
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.
Which situation is an example of the nurse fulfilling the role of client advocate?
- A. The nurse brings the client pain medication when it is due.
- B. The nurse collaborates with other disciplines during the care conference.
- C. The nurse contacts the health-care provider when pain relief is not obtained.
- D. The nurse teaches the client to ask for medication before the pain gets to a '5.'
Correct Answer: C
Rationale: Contacting the HCP for inadequate pain relief advocates for the client’s comfort. Bringing medication, collaborating, and teaching are supportive but less advocacy-focused.
Which situation demonstrates the circulating nurse acting as the client's advocate?
- A. Plays the client's favorite audio book during surgery.
- B. Keeps the family informed of the findings of the surgery.
- C. Keeps the operating room door closed at all times.
- D. Calls the client by the first name when the client is recovering.
Correct Answer: C
Rationale: Keeping the OR door closed maintains privacy and asepsis, advocating for client safety. Audio books, family updates, and name use are supportive but less critical.
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.