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The nurse is conducting an interview with a 75-year-old client admitted with acute pain. Which question would have priority when assisting with pain management?
- A. Have you ever had difficulty getting your pain controlled?
- B. What types of surgery have you had in the last 10 years?
- C. Have you ever been addicted to narcotics?
- D. Do you have a list of your prescription medications?
Correct Answer: A
Rationale: Asking about past pain control identifies effective strategies or barriers, guiding management. Surgical history, addiction, and medication lists are secondary.
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The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement?
- A. Place the sponge back where it was.
- B. Tell the technician not to waste supplies.
- C. Do nothing because this is the correct procedure.
- D. Take the sponge out of the room immediately.
Correct Answer: C
Rationale: Removing a potentially contaminated sponge from the sterile field edge is correct to maintain asepsis. Replacing, criticizing, or removing it immediately is incorrect.
The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage?
- A. The 16-year-old client in the dorsal recumbent position having an appendectomy.
- B. The 68-year-old client in the Trendelenburg position having a cholecystectomy.
- C. The 45-year-old client in the reverse Trendelenburg position having a biopsy.
- D. The 22-year-old client in the lateral position having a nephrectomy.
Correct Answer: D
Rationale: The lateral position risks brachial plexus or peroneal nerve damage due to pressure on dependent limbs, especially during prolonged surgery like nephrectomy. Other positions have lower nerve risks.
The nursing manager is making assignments for the OR. Which case should the manager assign to the inexperienced nurse?
- A. The client having open-heart surgery.
- B. The client having a biopsy of the breast.
- C. The client having laser eye surgery.
- D. The client having a laparoscopic knee repair.
Correct Answer: B
Rationale: Breast biopsy is a straightforward, low-risk procedure suitable for an inexperienced nurse. Open-heart, laser eye, and laparoscopic surgeries require advanced skills.
The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first?
- A. Apply antiembolism hose to the client.
- B. Attach the drain to 20 cm suction.
- C. Assess the client's vital signs.
- D. Listen to the report from the anesthesiologist.
Correct Answer: C
Rationale: Assessing vital signs establishes a baseline post-PACU, per ABCs. Antiembolism hose, drain attachment, and anesthesiologist report follow.
Which action by the client indicates to the nurse preoperative teaching has been effective?
- A. The client demonstrates how to use the incentive spirometer device.
- B. The client demonstrates the use of the patient-controlled analgesia pump.
- C. The client can name two (2) anesthesia agents used during surgery.
- D. The client ambulates down the hall to the nurse's station each hour.
Correct Answer: A
Rationale: Using the incentive spirometer correctly prevents atelectasis, a key preoperative teaching goal. PCA use is postoperative, naming agents is unnecessary, and hourly ambulation is excessive.