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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.
The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit. Which task can the nurse delegate to the UAP?
- A. Take routine vital signs on clients.
- B. Check the Jackson Pratt insertion site.
- C. Hang the client's next IV bag.
- D. Ensure the client obtains pain relief.
Correct Answer: A
Rationale: Taking vital signs is within UAP scope. Checking drains, hanging IVs, and ensuring pain relief require nursing assessment or licensure.
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 three (3)-day postoperative client is complaining of unrelieved pain at the incision site one (1) hour after the administration of narcotic pain medication. Which action should the nurse implement first?
- A. Check the MAR for another medication to administer.
- B. Teach the client to use guided imagery to relieve the pain.
- C. Assess the client for complications.
- D. Elevate the head of the client's bed.
Correct Answer: C
Rationale: Unrelieved pain post-narcotic may indicate complications (e.g., infection, hematoma), requiring assessment first. Additional medication, imagery, or HOB elevation follow.
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.