Nokea
The nurse is planning the care of the surgical client having procedural sedation. Which intervention has highest priority?
- A. Assess the client's respiratory status.
- B. Monitor the client's urinary output.
- C. Take a 12-lead ECG prior to injection.
- D. Attempt to keep the client focused.
Correct Answer: A
Rationale: Procedural sedation risks respiratory depression; assessing respiratory status is critical for safety. Urinary output, ECG, and focus are secondary.
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Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?
- A. Alteration in comfort.
- B. Disuse syndrome.
- C. Risk for injury.
- D. Altered gas exchange.
Correct Answer: C
Rationale: Risk for injury (e.g., from positioning, equipment) is a primary intraoperative concern, per NANDA-I. Comfort, disuse, and gas exchange are more postoperative or anesthesia-related.
Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain?
- A. Ineffective coping.
- B. Potential for injury.
- C. Alteration in comfort.
- D. Altered sensory input.
Correct Answer: C
Rationale: Alteration in comfort directly addresses acute pain’s impact, per NANDA-I. Coping, injury, and sensory input are secondary or unrelated.
Which client would the nurse identify as having the highest risk for developing postoperative complications?
- A. The 67-year-old client who is obese, has diabetes, and takes insulin.
- B. The 50-year-old client with arthritis taking nonsteroidal anti-inflammatory drugs.
- C. The 45-year-old client having abdominal surgery to remove the gallbladder.
- D. The 60-year-old client with anemia who smokes one (1) pack of cigarettes a day.
Correct Answer: A
Rationale: Obesity, diabetes, and insulin use increase risks for infection, poor wound healing, and glycemic instability, the highest risk profile. Arthritis, cholecystectomy, and anemia/smoking are less severe.
Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale (pointing to faces) is age-appropriate for a 4-year-old, per pediatric pain assessment guidelines. Simple words are vague, numeric scales are for older children, and scheduled medication is not assessment.
The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement?
- A. Insert an indwelling catheter.
- B. Increase the intravenous fluid rate.
- C. Assist the client to stand to void.
- D. Encourage the client to increase fluids.
Correct Answer: C
Rationale: Standing to void facilitates urination by using gravity, a non-invasive first step. Catheterization, IV fluids, and oral fluids are more invasive or secondary.