The nurse is interviewing a surgical client in the holding a...

The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply.

A. The client has loose, decayed teeth.
B. The client is experiencing anxiety.
C. The client smokes two (2) packs of cigarettes a day.
D. The client has had a chest x-ray which does not show infiltrates.
E. The client reports using herbs.

Correct Answer: A,C,E

Rationale: Loose teeth risk airway obstruction, smoking affects respiratory function and anesthesia, and herbs (e.g., ginseng) may interact with anesthesia, requiring anesthesiologist notification. Anxiety is common, and clear x-rays are reassuring.

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The postoperative client complains of hearing a 'popping sound' and feeling 'something opening' when ambulating in the room. Which intervention should the nurse implement first?

A. Notify the surgeon the client has had an evisceration.
B. Contact the surgery department to prepare for emergency surgery.
C. Assess the operative site and cover the site with a moistened dressing.
D. Explain this is a common feeling and tell the client to continue with activity.

Correct Answer: C

Rationale: A popping sound and opening sensation suggest dehiscence or evisceration; assessing and covering with a moist dressing stabilizes the site, the first step. Notification and surgery prep follow, and dismissing the symptom is unsafe.

The client diagnosed with appendicitis has undergone an appendectomy. At two (2) hours postoperative, the nurse takes the vital signs and notes T 102.6°F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority.

A. Increase the IV rate.
B. Notify the health-care provider.
C. Elevate the foot of the bed.
D. Check the abdominal dressing.
E. Determine if the IV antibiotics have been administered.

Correct Answer: C,A,B,D,E

Rationale: 1) Elevate foot of bed (Trendelenburg for hypotension); 2) Notify HCP (fever, tachycardia, hypotension suggest sepsis); 3) Increase IV rate (bolus for hypovolemia); 4) Check dressing (assess bleeding); 5) Confirm antibiotics (treat infection).

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.

The client has undergone an abdominal perineal resection of the colon for colon cancer with a left lower quadrant colostomy. Which interventions should the nurse implement? Select all that apply.

A. Assess the stoma for color every four (4) hours and prn.
B. Encourage the client to turn, cough, and deep breathe every two (2) hours.
C. Maintain the head of the bed 30 to 40 degrees elevated at all times.
D. Auscultate for bowel sounds every four (4) hours.
E. Administer pain medications sparingly to prevent addiction.

Correct Answer: A,B,D

Rationale: Stoma assessment monitors viability, coughing/deep breathing prevents atelectasis, and bowel sound checks assess GI function. HOB elevation is case-specific, and sparing pain medication risks undertreatment.

The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply.

A. Give a back rub to the client to relieve stiffness.
B. Apply ice packs to the axillary and groin areas.
C. Prepare an ice slush for the client to drink.
D. Prepare to administer dantrolene, a smooth-muscle relaxant.
E. Reposition the client on a warming blanket.

Correct Answer: B,D

Rationale: Tachycardia, hyperthermia, and muscle stiffness suggest malignant hyperthermia; ice packs cool the body, and dantrolene reverses the condition. Back rubs, ice slush, and warming blankets are inappropriate.