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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.
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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.
The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement?
- A. Prepare ice packs and mix dantrolene sodium.
- B. Request the defibrillator be brought into the OR.
- C. Draw a PTT and prepare a heparin drip.
- D. Obtain finger stick blood glucose immediately.
Correct Answer: B
Rationale: Tachycardia and hypotension suggest shock or arrhythmia, requiring a defibrillator for potential cardioversion. Dantrolene is for malignant hyperthermia, heparin for clotting, and glucose is unrelated.
The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery?
- A. The 65-year-old client who cannot read or write.
- B. The 30-year-old client who does not understand English.
- C. The 16-year-old client who has a fractured ankle.
- D. The 80-year-old client who is not oriented to the day.
Correct Answer: D
Rationale: Legal consent requires mental competency; disorientation to the day suggests incapacity. Illiteracy, language barriers (with interpreters), and minors (with parental consent) do not preclude consent.
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 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.