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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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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.
The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement?
- A. Notify the surgeon about the client's request to wear the medal.
- B. Tape the medal to the client and allow the client to wear the medal.
- C. Request the family member take the medal prior to surgery.
- D. Explain taking the medal to surgery is against the policy.
Correct Answer: B
Rationale: Taping the medal ensures safety (no loose objects) while respecting the client’s spiritual needs, per patient-centered care. Notification, removal, or policy citation are less accommodating.
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 client in the surgery holding area identifies the left arm as the correct surgical site, but the operative permit designates surgery to be performed on the right arm. Which interventions should the nurse implement? Select all that apply.
- A. Review the client's chart.
- B. Notify the surgeon.
- C. Immediately call a 'time-out.'
- D. Correct the surgical permit.
- E. Request the client mark the left arm.
Correct Answer: A,B,C
Rationale: Reviewing the chart verifies the correct site, notifying the surgeon addresses the discrepancy, and calling a time-out ensures team confirmation. Correcting the permit or marking the wrong site is unsafe.
Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the female client experiencing acute pain?
- A. Take the pain medication to the room.
- B. Apply an ice pack to the site of pain.
- C. Check on the client 30 minutes after she takes the pain medication.
- D. Observe the client's ability to use the PCA.
Correct Answer: B
Rationale: Applying an ice pack is a non-invasive task within UAP scope. Delivering medication, post-medication checks, and PCA observation require nursing judgment.