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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.
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The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first?
- A. Notify the client's surgeon.
- B. Complete an occurrence report.
- C. Contact the surgical manager.
- D. Recount all sponges.
Correct Answer: D
Rationale: Recounting sponges verifies the discrepancy, the first step to ensure no retained objects. Notification, reporting, or manager contact follow if confirmed.
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.
The nurse received a male client from the postanesthesia care unit. Which assessment data would warrant immediate intervention?
- A. The client's vital signs are T 97°F, P 108, R 24, and BP 80/40.
- B. The client is sleepy but opens the eyes to his name.
- C. The client is complaining of pain at a '5' on a 1-to-10 pain scale.
- D. The client has 20 mL of urine in the urinary drainage bag.
Correct Answer: A
Rationale: Tachycardia, tachypnea, and hypotension (80/40) suggest hypovolemic shock, requiring immediate intervention. Sleepiness, moderate pain, and low urine output are less urgent.
The surgical client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first?
- A. Call the surgeon and report the vital signs.
- B. Start an IV of D5RL with 20 mEq KCl at 125 mL/hr.
- C. Elevate the feet and lower the head.
- D. Monitor the vital signs every 15 minutes.
Correct Answer: C
Rationale: Tachycardia, hypotension, and pale, damp skin suggest hypovolemic shock; Trendelenburg position (feet elevated, head lowered) improves cerebral perfusion, the first intervention. Surgeon notification, IV fluids, and monitoring follow.
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.