Nokea
The nurse is receiving a client from the postanesthesia care unit (PACU). Which interventions should the nurse implement? Select all that apply.
- A. Ambulate the client to the bathroom to void.
- B. Take the client's vital signs to compare with PACU data.
- C. Monitor all lines into and out of the client's body.
- D. Assess the client's surgical site.
- E. Push the client's PCA button to treat for pain during movement.
Correct Answer: B,C,D
Rationale: Vital signs establish a baseline, line monitoring ensures patency, and surgical site assessment detects complications. Ambulation is premature, and nurses cannot push PCA buttons.
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Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?
- A. Loss of sensation at the lumbar (L5) dermatome.
- B. Absence of the client's posterior tibial pulse.
- C. The client has a respiratory rate of eight (8).
- D. The blood pressure is within 20% of the client's baseline.
Correct Answer: C
Rationale: A respiratory rate of 8 suggests respiratory depression, a serious spinal anesthesia complication. L5 numbness is expected, absent pulse suggests vascular issues, and stable BP is normal.
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.
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 circulating nurse observes the surgeon tossing a bloody gauze sponge onto the sterile field. Which action should the circulating nurse implement first?
- A. Include the sponge in the sponge count.
- B. Obtain a new sterile instrument pack.
- C. Tell the surgical technologist about the sponge.
- D. Throw the sponge in the sterile trashcan.
Correct Answer: C
Rationale: Telling the technologist ensures the contaminated sponge is removed from the sterile field, maintaining asepsis. Counting, new instruments, or trashing are secondary or incorrect.
Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Complete the preoperative checklist.
- B. Assess the client's preoperative vital signs.
- C. Teach the client about coughing and deep breathing.
- D. Assist the client to remove clothing and jewelry.
Correct Answer: D
Rationale: Removing clothing and jewelry is a non-invasive task within UAP scope. Checklist completion, vital signs, and teaching require nursing judgment.