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The nurse is completing the preoperative checklist on a client going to surgery. Which information should the nurse report to the surgeon?
- A. The client understands the purpose of the surgery.
- B. The client stopped taking aspirin three (3) weeks ago.
- C. The client uses the oral supplements licorice and garlic.
- D. The client has mild levels of preoperative anxiety.
Correct Answer: C
Rationale: Licorice and garlic may increase bleeding risk or interact with anesthesia, requiring surgeon notification. Understanding, aspirin cessation, and mild anxiety are expected or safe.
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The client is in the lithotomy position during surgery. Which nursing intervention should be implemented to decrease a complication from the positioning?
- A. Increase the intravenous fluids.
- B. Lower one leg at a time.
- C. Raise the foot of the stretcher.
- D. Administer epinephrine, a vasopressor.
Correct Answer: B
Rationale: Lowering legs sequentially prevents rapid blood pressure drops from venous pooling, reducing circulatory complications in lithotomy. Fluids, stretcher elevation, and epinephrine are unrelated.
Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?
- A. Change the dressing over the surgical site.
- B. Teach the client how to perform incentive spirometry.
- C. Empty and record the amount of drainage in the JP drain.
- D. Auscultate the bowel sounds in all four (4) quadrants.
Correct Answer: C
Rationale: Emptying and recording JP drain output is a technical task within UAP scope. Dressing changes, teaching, and auscultation require nursing judgment.
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.
Which nursing intervention is priority for the client experiencing acute pain?
- A. Assess the client's verbal and nonverbal behavior.
- B. Wait for the client to request pain medication.
- C. Administer the pain medication on a scheduled basis.
- D. Teach the client to use only imagery every hour for the pain.
Correct Answer: A
Rationale: Assessing verbal and nonverbal behavior determines pain severity and guides treatment, the priority. Waiting, scheduled dosing, or imagery alone delays or limits care.
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.